According to an August 2015 survey, 72 percent of Americans find drug costs unreasonable, with 83 percent believing that the federal government should be able to negotiate prices for Medicare. Recently, Acting Administrator of the Centers for Medicare and Medicaid Services (CMS) Andy Slavitt commented that spending on medicines increased 13 percent in 2014 while health care spending growth overall was only 5 percent, the highest rate of drug spending growth since 2001.

Some of the most expensive drugs are covered under Medicare’s medical benefit, Part B, because they are administered by a physician. They are often administered in hospital outpatient departments and physician offices, and most commonly used to treat conditions like cancer, rheumatoid arthritis, and macular degeneration. Between 2005 and 2014, spending on Part B drugs has increased annually by 7.7 percent, with the top 20 drugs by total amount of Medicare payments accounting for 57 percent of total Part B drug costs. While overall Part B drug spending is a small portion of Medicare drug spending, the high growth rate is a concern, especially as new expensive breakthrough cancer drugs enter the market and have a negative effect on consumers’ pockets.

Unlike Part D, the prescription drug benefit, there are fewer incentives built in to Part B for providers to consider lower cost treatments for patients even if the lower cost drug may be clinically equivalent to the more expensive drug, because prior to budget sequestration, providers received 6 percent on top of the Average Sales Price (ASP) of the drug. Larger providers and hospitals often receive discounts on these drugs as well, increasing the amount they receive directly on top of the out-of-pocket cost of the drug.

This leads to more out-of-pocket costs for the consumer, as patients usually pay 20 percent of Part B services. The Government Accountability Office (GAO) estimated that in 2013, among new drugs covered under Part B, nearly two-thirds had per beneficiary costs of over $9,000 per year, leading to out-of-pocket costs for consumers of amounts between $1,900 and $107,000 over the year. On top of these high costs, this can lead to problems with medication adherence, even for serious conditions such as cancer.

A New Payment Model

To help change these incentives and control costs, CMS has proposed a new demonstration program, which offers a few different reimbursement methods for Part B drugs. The program includes a geographically stratified design methodology to test and evaluate the different methods. One of the methods garnering a lot of attention is a proposal to lower the administration add-on payment to providers, from current 6 percent of ASP, to 2.5 percent plus a flat fee of $16.80 per administration day.

Policymakers, physician organizations, and patient advocacy organizations have voiced major concerns raising the alarm that this initiative will negatively affect patient access to vital drugs and therefore produce poorer patient outcomes. The sequester will also have a significant impact on the percentage add on, reducing it to closer to an estimated .86 percent plus the flat fee. But we believe the goals of the program and its potential to reduce costs represent an important step in the right direction. We hope the details can be further shaped by the important communities of providers and patients who will deliver and receive medical care.

Geographic Variation

Last year, we wrote a Health Affairs Blog that highlighted some of the uses and limitations of publicly available Part B physician payment data. One major use was to show the geographic variation in practice patterns and drug administration, and we particularly looked at the difference across states in Lucentis v. Avastin usage. As seen in Exhibit 1, variation in administration is wide among states, even though both are drugs used to treat the same condition, age-related macular degeneration, and were proven to have clinically similar outcomes, but the cost of Lucentis was $2,000 per dose, while Avastin was only $50 per dose.

Using the same price estimates from our previous research, which are from 2012, we found that physician reimbursement under the proposed demonstration would potentially change from $120 to $66.80 for Lucentis, and increase from $3 to $18.05 for Avastin. Under the first payment model, providers were receiving 40 times as much to administer Lucentis instead of Avastin, while under the new proposed payment model, they would only receive 3.7 times as much.

While still a formidable gap, this new policy would have decreased financial reimbursement for providers to administer Lucentis, a costly, clinically similar drug to the much cheaper Avastin. As seen in Exhibit 1, a majority of physicians prescribe Avastin, thus this policy will allow for increased reimbursement in those cases, but in states where Lucentis is prescribed in higher proportions, prescribing patterns might start to change as a result of the proposed demonstration.

Source: Author’s estimates using 2012 CMS Cost Data and Sequestration Estimates from DrugAbacus.org

The proposed demonstration program includes much more than the ASP modifications in its second phase, including:

• discounting or eliminating beneficiary copays,
• indication-based pricing that would vary payments based on the clinical effectiveness,
• reference pricing for similar drugs,
• risk-sharing agreements with drug manufacturers based on clinical outcomes of the drug, and
• creating clinical decision tools for providers to help develop best practices.

This is all at the same time that a new model in oncology care (OCM) is being launched, which could help to draw attention to total cost of care. It is important that CMS try to address rising drug costs, but also be sure to consider all relevant considerations during the comment period to fine-tune the proposal to avoid negative effects on beneficiaries’ care.

We believe CMS should consider offering a waiver for organizations already participating in Center for Medicare & Medicaid Innovation (CMMI) models like the OCM, because financial benchmarks are based on past performance and any savings recognized in the future could be artificial, attributable to this demonstration rather than to better care coordination and some of the other practice requirements that are part of the proposed OCM. Furthermore, because this demonstration sets a new research precedent and because it is mandatory in the selected study areas rather than voluntary, CMS must try to anticipate and avoid unintended consequences related to geographic stratification.

For example, it is possible to imagine organizations with multiple locations directing patients to optimal sites for their business. Also, without a control group, some findings may be unreliable. The proposed rule currently lacks much detail, and there does not seem to be enough time for organizations to evaluate the impact of the proposed rule on their operations. Having said that, it will be important for stakeholders of all types to submit comments to the proposed rule in an effort to improve the final rule prior to implementation.

The critical question for the policymakers and stakeholders is whether this model can align with the multitude of other payment model reforms — unintended consequences could mitigate all the positive outcomes that a CMMI model offers to beneficiaries. Helping beneficiaries is and should be CMS’ ultimate obligation.

Editor’s Note: This analysis is part of The Leonard D. Schaeffer Initiative for Innovation in Health Policy, which is a partnership between the Center for Health Policy at Brookings and the USC Schaeffer Center for Health Policy and Economics. The Initiative aims to inform the national health care debate with rigorous, evidence-based analysis leading to practical recommendations using the collaborative strengths of USC and Brookings.

The passage of the Medicare Access and CHIP Reauthorization Act (MACRA) just over a year ago signaled a strong and unique bipartisan agreement to move towards value-based care, but until recently, many of the details surrounding how it would be implemented remained unknown. But last week, the Centers for Medicare and Medicaid Studies (CMS) released roughly 1,000 pages that shed more light on how physician payment will hopefully dramatically change for the better.

Some Historical Context

Prior to MACRA, how doctors were paid for providing care to Medicare patients was subject to a reimbursement formula known as the Sustainable Growth Rate (SGR). Established in 1997 to control the rate of increase in spending on physician services, the SGR pegged total spending among all Medicare-participating physicians to an overall budget target. Yet in this “tragedy of the commons,” no one physician benefitted from her good stewardship of health care resources. Total physician spending often exceeded the overall budget target, triggering reimbursement rate cuts. However, lawmakers chose to push them off into the future through what were called “doc fixes,” deferring the rate cuts temporarily. The pending cut rose to over 21 percent before MACRA’s passage as a result of compounding doc fixes.

Moving Forward with MACRA

When it was signed into law on April 16, 2015, MACRA ended the SGR, its cuts, and many previous payment incentive programs. In their place, MACRA established two overarching payment incentive schemes for providers to choose from:

1. the Merit-Based Incentive Payment System (MIPS) program, which supplants three previous payment incentives and makes positive or negative adjustments to a physician’s payment based on her performance; or


2. the Alternative Payment Model (APM) program, which awards a 5 percent bonus through 2024—with higher annual payment updates thereafter—for having a minimum percentage of Medicare and/or all-payer revenue through eligible APMs. Base physician fee rates for all Medicare providers would be updated 0.5 percent for each of the first four years, followed by no increases until 2026, when base fees would increase at different rates depending on the payment incentive program in which a physician participates.

MIPS addresses providers’ longstanding complaints that reporting that reporting under the existing programs—the Physician Quality Reporting System, the Value-Based Modifier, and Meaningful Use — is duplicative and cumbersome. Under the new MIPS program, physicians report to the government payer directly (CMS) and receive a bonus or penalty based on performance on measures of quality, resource use, meaningful use of electronic health records, and clinical practice improvement activities. The bonus or penalty physicians may see starts at 4 percent of the fee schedule in 2019 (based on their performance two years prior—in this case 2017) and increases successively to 5 percent in 2020, 7 percent in 2021, and 9 percent from 2022 onward. From 2026 onward, MIPS providers would receive an annual increase of 0.25 percent on their base fee schedules rates.

In contrast, the APM incentive program awards qualifying physicians a fixed, annual bonus of 5 percent of their reimbursement from 2019- – 2024, and provides that their fee schedule rates grow 0.5 percentage points faster than those of MIPS in 2026 and beyond, in recognition of the risk they assume in these contracts.

Yet, according to MACRA, not all APMs are created equal. APMs eligible for this track must use quality measures similar to those of MIPS, ensure electronic health records are used, and either be an approved patient-centered medical home (PCMH) or require that the participating entity “bears more than nominal financial risk” for excessive costs. Then, in order to receive the APM track bonus, physicians must have a minimum of 25 percent of their revenue from Medicare come through eligible APMs in 2019, with the minimum increasing through 2023 up to 75 percent. In 2021, a new all-payer Advanced APM option becomes available, allowing providers in APM contracts with other payers to participate in the Advanced APM incentive. To do so, they must meet the same minimum thresholds—50 percent in 2021, 75 percent in 2023—but through all provider contracts, not solely Medicare revenue, while still meeting a significantly lower Medicare-specific threshold. By creating an all-payer option, CMS hopes to enable greater provider participation by allowing all payer revenue to count toward the same minimum threshold. Under the all-payer model in 2021, for example, providers must have no less than 25 percent of Medicare revenue through Advanced APMs and 50 percent of all revenue through Advanced APMs.

MACRA Implementation Details Revealed

The newly released proposed rule provides answers to significant questions that had been left unanswered in the law surrounding the specifics of implementation of MIPS and the APM incentives. At long last, providers are gleaning insight into how CMS intends to implement MIPS and the APM track. Given the fast-approaching MIPS performance period in January 2017, here are three key highlights providers need to know:

1. Qualifying for the APM incentive track—and getting out of MIPS—will be difficult. In order to qualify for the bonus-awarding Advanced APM designation, APMs must meet the “nominal financial risk” criteria, which will be measured in three ways: an APM’s marginal rate sharing for losses, minimum loss ratio (the threshold above which providers would begin sharing in losses), and total potential risk as a percent of expected costs. Clinicians must further have a minimum share of revenue that comes in through the designated APMs.


2. Providers will have fewer opportunities to see and improve their performance on MIPS. Despite calls from provider groups for more frequent reporting and feedback periods, MIPS reporting periods will be annual, not quarterly. This is true for performance feedback from CMS, as well, though they may explore more frequent feedback cycles in the future. Quarterly reporting and feedback periods could have made the incentive programs more “actionable” for providers, alerting them to their performance closer to the time the services were rendered and providing more opportunities to improve performance.


3. MIPS allows greater flexibility than previous programs. Put simply, MIPS is the performance incentive program clinicians will participate in if not on the Advanced APM track. While compelling participation, the proposed MIPS implementation also responds to stakeholder concerns that earlier performance incentive programs were onerous and sometimes irrelevant—MIPS reduces the number of measures required in some categories and allows physicians to select from a set of measures to report on based on relevancy to their practice.

With last week’s release of the proposed rule, the Leonard D. Schaeffer Initiative for Innovation in Health Policy is kicking off a series of work products that will focus dually on further MACRA implementation issues and on translating complex policy into providers’ experience. In the blogs and publications to follow, we will dive into greater detail and discussion of the pieces of MACRA implementation highlighted here, as well as many other emerging physician payment reform issues, as the law’s implementation unfolds.

The Center for Medicare and Medicaid Innovation (CMMI, or “the Innovation Center”) recently announced an initiative called Comprehensive Primary Care Plus (CPC+). It evolved from the Comprehensive Primary Care (CPC) initiative, which began in 2012 and runs through the end of this year. Both initiatives are designed to promote and support primary care physicians in organizing their practices to deliver comprehensive primary care services. Comprehensive Primary Care Plus has some very promising components, but also misses some compelling opportunities to further advance payment for primary care services.

The earlier initiative, CPC, paid qualified primary care practices a monthly fee per Medicare beneficiary to support practices in making changes in the way they deliver care, centered on five comprehensive primary care functions: (1) access and continuity; (2) care management; (3) comprehensiveness and coordination; (4) patient and caregiver engagement; and, (5) planned care and population health. For all other care, regular fee-for-service (FFS) payment continued. The initiative was limited to seven regions where CMMI could reach agreements with key private insurers and the Medicaid program to pursue a parallel approach. The evaluation funded by CMMI found quality improvements and expenditure reductions, but savings did not cover the extra payments to practices.

Comprehensive Primary Care Plus uses the same strategy of conducting the experiment in regions where key payers are pursuing parallel efforts. In these regions, qualifying primary care practices can choose one of two tracks. Track 1 is very similar to CPC. The monthly care management fee per beneficiary remains the same, but an extra $2.50 is paid in advance, subject to refund to the government if a practice does not meet quality and utilization performance thresholds.

The Promise Of CPC+

Track 2, the more interesting part of the initiative, is for practices that are already capable of carrying out the primary care functions and are ready to increase their comprehensiveness. In addition to a higher monthly care management fee ($28), practices receive Comprehensive Primary Care Payments. These include a portion of the expected reimbursements for Evaluation and Management services, paid in advance, and reduced regular fee-for-service payments. Track 2 also includes larger rewards than does Track 1 for meeting performance thresholds.

The combination of larger per beneficiary monthly payments and lower payments for services is the most important part of the initiative. By blending capitation (monthly payments not tied to service volume) and FFS, this approach might achieve the best of both worlds.

Even when FFS payment rates are calibrated correctly (discussed below), the rates are pegged to the average costs across practices. But since a large part of practice cost is fixed, it means that the marginal cost of providing additional services is lower than the average cost, leading to incentives to increase volume under FFS. The lower payments reduce or eliminate these incentives. Fixed costs, which must also be covered, are addressed through the Comprehensive Primary Care Payments. By involving multiple payers, practices are put in a better position to pursue these changes.

An advantage of any program that increases payments to primary care practices is that it can partially compensate for a flaw in the relative value scale behind the Medicare physician fee schedule. This flaw leads to underpayment for primary care services. Although the initial relative value scale implemented in 1992 led to substantial redistribution in favor of evaluation and management services and to physicians who provide the bulk of them, a flawed update process has eroded these gains over the years to a substantial degree.

In response to legislation, the Centers for Medicare and Medicaid Services are working correct these problems, but progress is likely to come slowly. Higher payments for primary care practices through the CPC+ can help slow the degree to which physicians are leaving primary care until more fundamental fixes are made to the fee schedule. Indeed, years of interviews with private insurance executives have convinced us that concern about loss of the primary care physician workforce has been a key motivation for offering higher payment to primary care physicians in practices certified as patient centered medical homes.

Two Downsides

But there are two downsides to the CPC+.

One concerns the lack of incentives for primary care physicians to take steps to reduce costs for services beyond those delivered by their practices. These include referring their patients to efficient specialists and hospitals, as well as limiting hospital admissions. There are rewards in CPC+ for lower overall utilization by attributed beneficiaries and higher quality, but they are very small.

We had hoped that CMMI might have been inspired by the promising initiatives of CareFirst Blue Cross Blue Shield and the Arkansas Health Care Improvement initiative, which includes the Arkansas Medicaid program and Arkansas Blue Cross Blue Shield. Under those programs, primary care physicians are offered substantial bonuses for keeping spending for all services under trend for their panel of patients; there is no downside risk, which is understandable given the small percentage of spending accounted for by primary care. The private and public payers also support the primary care practices with care managers and with data on all of the services used by their patients and on the efficiency of providers they might refer to. These programs appear to be popular with physicians and have had promising early results.

The second downside concerns the inability of physicians participating in CPC+ to participate in accountable care organizations (ACOs). One of CMMI’s challenges in pursuing a wide variety of payment innovations is apportioning responsibility across the programs for beneficiaries who are attributed to multiple payment reforms. As an example, if a beneficiary attributed to an ACO has a knee replacement under one of Medicare’s a bundled payment initiatives, to avoid overpayment of shared savings, gains or losses are credited to the providers involved in the bundled payment and not to the ACO. As a result, ACOs are no longer rewarded for using certain tools to address overall spending, such as steering attributed beneficiaries to efficient providers for an episode of care or encouraging primary care physicians to increase the comprehensiveness of the care they deliver.

Keeping the physician participants in CPC+ out of ACOs altogether seems to be another step to undermine the potential of ACOs in favor of other payment approaches. This is not wise. The Innovation Center has appropriately not established a priority ranking for its various initiatives, but some of its actions have implicitly put ACOs at the bottom of the rankings. Recently, Mostashari, Kocher, and McClellan proposed addressing this issue by adding a CPC+ACO option to this initiative.

In an update to its FAQ published May 27, 2016 (after out blog was put into final form), CMMI eased its restriction somewhat by allowing up to 1,500 of the 5000 practices expected to participate in CPC+ to also participate in Medicare Shared Savings Program (MSSP) ACOs. But the prohibition continues to apply to Next Gen ACOs, the model that has created the most enthusiasm in the field. If demand for these positions in MSSP ACOs exceeds 1,500, a lottery will be held. This change is welcome but does not really address the issue of disadvantaging ACOs in situations where a beneficiary is attributed to two or more payment reform models. CMMI is sending a signal that CPC+, notwithstanding its lack of incentives concerning spending outside of primary care, is a powerful enough reform that diverting practices away from ACOs is not a problem. ACOs are completely dependent on primary care physician membership to function, meaning that any physician practices beyond 1,500 that enroll in CPC+ will reduce the size and the impact of the ACO program. CMMI has never published a priority ranking of reform models, but its actions keep indicating that ACOs are at the bottom.

The Innovation Center should be lauded for continuing to support improved payment models for primary care. Its blending of substantial monthly payments with lower payments per service is promising. But the highest potential rewards come from broadening primary care physicians’ incentives to include the cost and quality of services by other providers. CMMI should pursue this approach.

Editor's note: This piece originally appeared in Health Affairs Blog.

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.

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

As the nation still struggles with high healthcare costs that consume larger and larger portions of patient budgets as well as government coffers, the search for ways to get costs under control continues. Total healthcare spending in the U.S. now represents almost 18 percent of our entire economy. One promising cost-savings approach is called “reference pricing,” where the insurer establishes a price ceiling on selected services (joint replacement, colonoscopy, lab tests, etc.). Often, this price cap is based on the average of the negotiated prices for providers in its network, and anything above the reference price has to be covered by the insured consumer.

A study published in JAMA Internal Medicine by James Robinson and colleagues analyzed grocery store Safeway’s experience with reference pricing for laboratory services such as such as a lipid panel, comprehensive metabolic panel or prostate-specific antigen test. Safeway’s non-union employees were given information on prices at all laboratories through a mobile digital platform and told what Safeway would cover. Patients who chose a lab charging above the payment limit were required to pay the full difference themselves.

Employers see this type of program as a way to incentivize employees to think through the price of services when making healthcare decisions. Employees enjoy savings when they switch to a provider whose negotiated price is below the reference price, whereas if they choose services above it, they are responsible for the additional cost.

Robinson’s results show substantial savings to both Safeway and to its covered employees from reference pricing. Compared to trends in prices paid by insurance enrollees not subject to the caps of reference pricing, costs paid per test went down almost 32 percent, with a total savings over three years of $2.57 million – patients saved $1.05 million in out-of-pocket costs and Safeway saved $1.7 million.

I wrote an accompanying editorial in JAMA Internal Medicine focusing on different types of consumer-driven approaches to obtain lower prices; I argue that approaches that make the job simpler for consumers are likely to be even more successful. There is some work involved for patients to make reference pricing work, and many may have little awareness of price differences across laboratories, especially differences between those in some physicians’ offices, which tend to be more expensive but also more convenient, and in large commercial laboratories. Safeway helped steer their employees with accessible information: they provided employees with a smartphone app to compare lab prices.

But high-deductible plans like Safeway’s that provide extensive price information to consumers often have only limited impact because of the complexity of shopping for each service involved in a course of treatment -- something close to impossible for inpatient care. In addition, high deductibles are typically met for most hospitalizations (which tend to be the very expensive), so those consumers are less incentivized to comparison shop.

Plans that have limited provider networks relieve the consumer of much complexity and steer them towards providers with lower costs. Rather than review extensive price information, the consumer can focus on whether the provider is in the network. Reference pricing is another approach that simplifies—is the price less than the reference price? What was striking about Robinson’s results is that reference pricing for laboratories was employed in a high-deductible plan, showing that the savings achieved—in excess of 30 percent compared to a control—were beyond what the high deductible had accomplished.

While promising, reference pricing cannot be applied to all medical services: it works best for standardized services and where variation in quality is less of a concern. It also can be applied only to services that are “shoppable,” which is only about one-third of privately-insured spending. Even if reference pricing expanded to a number of other medical services, other cost containment approaches, including other network strategies, are needed to successfully contain health spending and lower costs for non-shoppable medical services.

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

Event Information

President Barack Obama took office in early 2009 with an ambitious foreign policy agenda for the Americas. In April of that year, his keynote remarks at the fifth Summit of the Americas emphasized the United States’ new course of seeking equal partnership and collaboration in the region.

On June 29, the Latin America Initiative at Brookings and the Corporación Andina de Fomento (CAF) brought together experts from the region to discuss the significance of this renewed hemispheric partnership and featured a keynote address from Arturo Valenzuela, assistant secretary of state for Western Hemisphere affairs. Panelists included: Craig Kelly, principal deputy assistant secretary for Western Hemisphere Affairs at the U.S. Department of State; Michael Shifter, president of the Inter-American Dialogue; Luis Enrique Berrizbeitia, executive vice-president of the Corporación Andina de Fomento (CAF); and Kevin Casas-Zamora, senior fellow at Brookings. They took a closer look at the idea of partnership in the region, reviewed the progress that has been made, explored opportunities that exist for the future and discussed the realities of developing collaborative policies in the region across a wide range of topics, including energy and climate change. The discussion also revisited the policy recommendations made by Brookings‘s Partnership for the Americas Commission.

Video

• A Confident and Strong Latin America
• Adaptable Latin America Policy
• Four Pillars of U.S. Strategy
• Need a Strong U.S. Relationship with Brazil

Audio

• Latin America and the Obama Administration: A New Partnership?

Transcript

• Transcript (.pdf)

Event Materials

• 20100629_americas_partnership

President Obama arrived in Panama for the seventh Summit of the Americas with a clear mission: restore the feel-good atmosphere of his first regional summit in Trinidad. There he received plaudits as the first African-American president, a post-unilateralist leader for a more multipolar world. Six years later, and with a complicated record to defend, he had to work harder for the ovations. But his administration’s efforts paid off, and he left Panama a winner. The President’s decision to remove Cuba from the dreaded U.S. list of state sponsors of terrorism is further demonstration that Obama is convinced that U.S. interests in Cuba are best served through constructive engagement and not onerous sanctions. Now he must persuade Congress.

First and foremost, the Panama Summit will be remembered for cementing the historic process of normalization of ties between the United States and Cuba launched by Presidents Obama and Raúl Castro on December 17. The Panama meeting offered a chance not only for the rest of the region to ratify Obama’s overture to Castro, but to close the books on the Cold War and open a new chapter in inter-American relations. Bill Clinton led the way on this track in the 1990s, but the train got derailed in the 2000s under George W. Bush. The ghosts of Washington’s heavy-handed past, on matters such as the war on drugs, immigration, counter-terrorism, and the hangover of the “Washington consensus,” returned to haunt Obama’s second summit in Cartagena in 2012. The White House was determined to re-set course before sitting through another series of harangues against the sins of the past by delivering important progress on several policy fronts in the months leading up to Panama. 

No issue was more representative of U.S. bullying in the region than the decades-old embargo against Cuba. When the region’s presidents said they would not come to Panama unless Cuba was invited as a full participant, the White House was forced to fish or cut bait. Correctly, President Obama chose to fish. The breakthrough of December 17 was rewarded with widespread praise by his counterparts and by publics in both the United States and Cuba. The president’s main task for Panama, then, was to deliver a winning message for the first face-to-face meeting in over five decades of hostilities.

Source: REUTERS/Jonathan Ernst

No image better captures the competing narratives of the deep historical differences between the United States and Cuba than the one above. The elder Raúl Castro, who does not have to worry about his state-controlled media, plugs his ears to drown out the clamor of journalists asking questions after the two leaders’ first meeting, while the younger Obama is ready to engage the press, a customary stance for leaders in a democracy.

The contrast between old and new continued in the plenary where Obama gave a focused presentation  about moving beyond “the old grievances that had too often trapped us in the past” to a future based on shared responsibility and mutual respect. “We’re looking to the future and to policies that improve the lives of the Cuban people.”

Castro, on the other hand, multiplied his allotted eight minutes of remarks to 48 (to make up for the six summits Cuba was not invited to, he joked) to recount a long litany of transgressions by previous U.S. governments dating back to 1800. He reminded the audience of Washington’s overthrow of the democratically-elected government of Guatemala in 1954 as the precursor to Cuba’s own popular revolution and invoked his brother Fidel in blaming global poverty on the aggressions of colonial and imperialist powers. Remarkably, however, Castro specifically absolved President Obama from any responsibility for such actions, an important gesture that opens the door for more progress. “President Obama is an honest man…I admire his humble origins,” Castro said, and urged others to support his efforts to eliminate the embargo. Castro also said Cuba was prepared to work with the United States on such issues as climate change, terrorism, drug trafficking, organized crime, and poverty eradication.

With the removal of Cuba from the U.S. list of state sponsors of terrorism, and the last-minute softening of U.S. rhetoric toward Cuba’s chief ally, Venezuela, the Americas may be entering an unprecedented era of peace and cooperation. That leaves respect for democracy and human rights as the chief area of conflict between the United States and Cuba (and a few other countries).

Here again, the contrast between the behavior of pro- and anti-government Cuban activists emerged in sharp relief in Panama. Highly aggressive actions by “official” Cuban nongovernmental organizationss against dissidents from Cuba and Miami, including physical and verbal insults and attacks, were completely out of tune with the modern era of inclusion and respect of independent civil society voices at such meetings. Their orchestrated disruptions of what should have been a robust but civil debate laid bare the real threat Cuba’s rulers face—from its own public tired of the regime’s broken economic system and closed politics—and the heavy challenge they face in opening economically while maintaining political control. President Obama spoke to this issue when he told the press: “On Cuba, we are not in the business of regime change. We are in the business of making sure the Cuban people have freedom and the ability to…shape their own destiny.” The primary way to do this, Obama added, is through “persuasion” and not sanctions. Cuba’s behavior “does not implicate our national security in a direct way,” foreshadowing this week’s decision to de-list Cuba from the terrorism sponsor category.

Cuban officials claim they are practicing a form of popular democracy that is just as legitimate as representative democracy. But few honestly believe this can be squared with core universal norms like free speech and association. For his part, Castro acknowledged that “[w]e could be persuaded of some things; of others we might not be persuaded.” Patience, he added, is needed, signaling yet again that progress toward normalizing relations will be slow. He then proceeded to instruct his closest assistants to “follow the instructions of both Presidents,” a telling reminder of the continued resistance to change from his own bureaucracy. Obama will now have to persuade his colleagues in Congress that Cuba is no longer the threat it was in the past.

It seems the Senate could have a really hot summer. Majority leader Harry Reid (D-NV) has reportedly threatened to “go nuclear” this July—meaning that Senate Democrats would move by majority vote to ban filibusters of executive and judicial branch nominees. According to these reports, if Senate Republicans block three key nominations (Richard Cordray to head the Consumer Financial Protection Bureau, Thomas Perez at Labor, and Gina McCarthy at EPA), Reid will call on the Democrats to invoke the nuclear option as a means of eliminating filibusters over nominees.

Jon Bernstein offered a thoughtful reaction to Reid’s gambit, noting that Reid’s challenge is to “find a way to ratchet up the threat of reform in order to push Republicans as far away from that line as possible.” Jon’s emphasis on Reid’s threat is important (and is worth reading in full).  Still, I think it’s helpful to dig a little deeper on the role of both majority and minority party threats that arise over the nuclear option.

Before getting to Reid’s threat, two brief detours. First, a parliamentary detour to make plain two reasons why Reid’s procedural gambit is deemed “nuclear.” First, Democrats envision using a set of parliamentary moves that would allow the Senate to cut off debate on nominations by majority vote (rather than by sixty votes). Republicans (at least when they are in the minority) call this “changing the rules by breaking the rules,” because Senate rules formally require a 2/3rds vote to break a filibuster of a measure to change Senate rules. The nuclear option would avoid the formal process of securing a 2/3rds vote to cut off debate; instead, the Senate would set a new precedent by simple majority vote to exempt nominations from the reach of Rule 22. If Democrats circumvent formal rules, Republicans would deem the move nuclear. Second, Reid’s potential gambit would be considered nuclear because of the anticipated GOP reaction: As Sen. Schumer argued in 2005 when the GOP tried to go nuclear over judges, minority party senators would “blow up every bridge in sight.” The nuclear option is so-called on account of the minority’s anticipated parliamentary reaction (which would ramp up obstruction on everything else).

A second detour notes simply that the exact procedural steps that would have to be taken to set a new precedent to exempt nominations from Rule 22 have not yet been precisely spelled out.  Over the years, several scenarios have been floated that give us a general outline of how the Senate could reform its cloture rule by majority vote. But a CRS report written in the heat of the failed GOP effort to go nuclear in 2005 points to the complications and uncertainties entailed in using a reform-by-ruling strategy to empower simple majorities to cut off debate on nominations. My sense is that using a nuclear option to restrict the reach of Rule 22 might not be as straight forward as many assume.

That gets us to the place of threats in reform-by-ruling strategies. The coverage of Reid’s intentions last week emphasized the importance of Reid’s threat to Republicans: Dare to cross the line by filibustering three particular executive branch nominees, and Democrats will go nuclear. But for Reid’s threat to be effective in convincing GOP senators to back down on these nominees, Republicans have to deem Reid’s threat credible. Republicans know that Reid refused by go nuclear last winter (and previously in January 2009), not least because a set of longer-serving Democrats opposed the strategy earlier this year. It would be reasonable for the GOP today to question whether Reid has 51 Democrats willing to ban judicial and executive branch nomination filibusters. If Republicans doubt Reid’s ability to detonate a nuclear device, then the threat won’t be much help in getting the GOP to back down. Of course, if Republicans don’t block all three nominees, observers will likely interpret the GOP’s behavior as a rational response to Reid’s threat. Eric Schickler and Greg Wawro in Filibuster suggest that the absence of reform on such occasions demonstrates that the nuclear option can “tame the minority.”  Reid’s threat would have done the trick.

As a potentially nuclear Senate summer approaches, I would keep handy an alternative interpretation.  Reid isn’t the only actor with a threat: given Republicans’ aggressive use of Rule 22, Republicans can credibly threaten to retaliate procedurally if the Democrats go nuclear.  And that might be a far more credible threat than Reid’s. We know from the report on Reid’s nuclear thinking that “senior Democratic Senators have privately expressed worry to the Majority Leader that revisiting the rules could imperil the immigration push, and have asked him to delay it until after immigration reform is done (or is killed).” That tidbit suggests that Democrats consider the GOP threat to retaliate as a near certainty. In other words, if Republicans decide not to block all three nominees and Democrats don’t go nuclear, we might reasonably conclude that the minority’s threat to retaliate was pivotal to the outcome. As Steve Smith, Tony Madonna and I argued some time ago, the nuclear option might be technically feasible but not necessarily politically feasible.

To be sure, it’s hard to arbitrate between these two competing mechanisms that might underlie Senate politics this summer.  In either scenario—the majority tames the minority or the minority scares the bejeezus out of the majority—the same outcome ensues: Nothing. Still, I think it’s important to keep these alternative interpretations at hand as Democrats call up these and other nominations this spring. The Senate is a tough nut to crack, not least when challenges to supermajority rule are in play.

UPDATE 4: Sarah Binder explores the questions, "Why did the Senate go nuclear now, and what will be the consequences for future majorities eager to further curtail the filibuster?"

UPDATE 2: Sarah Binder writes that "this is big" in another new post on Monkey Cage blog, "Boom! What the Senate will be like when the nuclear dust settles." 

UPDATE: Sarah Binder has a new post on Monkey Cage blog, in which she explains why GOP targeting of the D.C. circuit may not be as unprecedented as some think and why it would be difficult to parse out "acceptable" filibusters from those that aren't. "We'll learn soon enough," Binder writes, "if Democrats have the guts to go [nuclear] and, if so, whether that compels any Republicans to stand down."

Over the past few weeks, Senate Republicans have filibustered President Obama's three nominees to the Court of Appeals for the D.C. Circuit, claiming alternatively that Obama was trying to pack the court and characterizing the court's caseload as lighter than other circuits. News reports now say that Senate Majority Leader Harry Reid is considering changing the filibuster rule for some executive and judicial nominees, the so-called "nuclear option.

In 2010, Brookings Senior Fellow Sarah Binder, an expert on Congress and congressional history, testified to the Senate that "the filibuster was created by mistake."

We have many received wisdoms about the filibuster. However, most of them are not true. The most persistent myth is that the filibuster was part of the founding fathers’ constitutional vision for the Senate: It is said that the upper chamber was designed to be a slow-moving, deliberative body that cherished minority rights. In this version of history, the filibuster was a critical part of the framers’ Senate.

However, when we dig into the history of Congress, it seems that the filibuster was created by mistake. Let me explain.

The House and Senate rulebooks in 1789 were nearly identical. Both rulebooks included what is known as the “previous question” motion. The House kept their motion, and today it empowers a simple majority to cut off debate. The Senate no longer has that rule on its books.

What happened to the Senate’s rule? In 1805, Vice President Aaron Burr was presiding over the Senate (freshly indicted for the murder of Alexander Hamilton), and he offered this advice. He said something like this. You are a great deliberative body. But a truly great Senate would have a cleaner rule book. Yours is a mess. You have lots of rules that do the same thing. And he singles out the previous question motion. Now, today, we know that a simple majority in the House can use the rule to cut off debate. But in 1805, neither chamber used the rule that way. Majorities were still experimenting with it. And so when Aaron Burr said, get rid of the previous question motion, the Senate didn’t think twice. When they met in 1806, they dropped the motion from the Senate rule book.

Why? Not because senators in 1806 sought to protect minority rights and extended debate. They got rid of the rule by mistake: Because Aaron Burr told them to.

Once the rule was gone, senators still did not filibuster. Deletion of the rule made possible the filibuster because the Senate no longer had a rule that could have empowered a simple majority to cut off debate. It took several decades until the minority exploited the lax limits on debate, leading to the first real-live filibuster in 1837.

Binder makes additional insightful points about the origin and historical uses of the Senate filibuster in that testimony to the Senate Rules and Administration Committee.

She also calls attention to another of Obama's recent judicial nominees: Ronnie White for the U.S. District Court for the Eastern District of Missouri, which is yet another window, she says, on the "evolving wars of advice and consent."

Binder also has data on whether Senate Minority Leader Mitch McConnell and the Senate GOP have "played fair" on President Obama's nominees.

For additional analysis about the filibuster, see Binder's "What Senate cloture votes tell us about obstruction," in which she wrote:

Ultimately, the rise of the 60-vote Senate in a period of polarized parties signals that the minority party has mastered the art of blocking the majority. Sometimes, the minority leader drives the opposition in his conference; other times, he follows it. Regardless, what’s true of the tango is also true of the Senate: It takes two parties to make it look good. The minority party no doubt often feels that the majority leader is too quick to call for a vote, and its members might reasonably oppose cloture on that ground. However, my sense is that far more often, majority leaders resort to cloture when they find themselves unable to cajole the minority party to cooperate. As the Senate GOP conference fractures between pragmatists and ideologues, securing GOP consent will likely become even harder. Counting cloture votes remains an imperfect — but still valid — method of capturing minority efforts to block the Senate.

Get all of Sarah Binder's research and commentary about the Senate filibuster on her bio page.

Sen. Harry Reid has gone ahead with the so-called "nuclear option" to attempt to change Senate filibuster rules on some executive branch nominations, passing the rule change with a 52-48 vote. In their Vital Statistics on Congress report, Brookings Senior Fellow Thomas Mann and AEI Resident Scholar Norman Ornstein provide data on the number of attempted Senate cloture votes taken from 1979 to 2012, the 96th to 112th Congresses. The chart below demonstrates the average attempted cloture vote taken by party when that party was in the minority.

For more data on both attempted and successful cloture votes sine 1919, look up table 6-7 in Vital Stats (PDF).

Senior Fellow Sarah Binder, a leading expert on Congress and congressional history who called, in 2010, the Senate filibuster a "mistake," offered a recent analysis of Senate cloture votes, writing that "Counting cloture votes remains an imperfect — but still valid — method of capturing minority efforts to block the Senate."

More recently, Binder wondered whether "Democrats have the guts to go there and, if so, whether that compels any Republicans to stand down."

HHS Secretary Kathleen Sebelius may lose the most from the Senate’s rule change on the filibuster—and the Affordable Care Act may be healthier for it. I wrote last month on the FixGov blog that “Republicans are the Reason Secretary Sebelius Won’t Resign” (or be fired). That argument is no longer valid. My claim—the president’s inability to get her successor confirmed because of filibustering Republicans—is nullified by the Senate’s rule change, and the benefits may reach far beyond Obamacare.

The Implications of Filibuster Reform for Healthcare

Problems exist in HHS. No one denies it. However, for many appointees in the Department, the Senate rules served as a life preserver in a torrent of poor implementation, managerial failures, and bad PR. So long as the president faced the prospect of long-term vacancies among appointees overseeing ACA, the HHS leadership would be spared.

Today, that all changed. Moving forward, President Obama needs the support of only 51 Senate Democrats to replace top-level political appointees throughout the executive branch. This offers the president substantial breathing room. Nominees no longer need the support of every Democrat and a scarcely identifiable five Republicans. Instead, nominees can draw the ire of as many as four Democrats and still be confirmed.

Maybe Kathleen Sebelius is not to blame for the botched healthcare marketplace roll out. Maybe her Office did not give the thumbs up for the President to repeat “if you like your plan you can keep it.” Maybe she did not contribute to the poor salesmanship of the legislation from the start. However, if she was to blame (and perhaps if she wasn’t), her days in the president’s cabinet may well be numbered. The same may be true for deputies and other administrators in the Department who oversaw the weaker areas of the roll out of this law.

By repositioning HHS personnel or breathing new life into a Department facing continued struggles, the president may well ensure the administration of his signature legislation accomplishment improves. The right appointees can coordinate and communicate policy needs and goals up and down the bureaucratic hierarchy. Rather than settling for a program that meets or falls short of expectations, there is an opportunity to build an effective ACA.

Good Governance beyond Obamacare

The first half of October showed us that political actors in Congress contributed to a broken legislative branch. The second half of October showed us that political actors in the Administration contributed to a broken executive branch. Now is the time for the president to start anew and fix one branch, in the shadow of a Senate trying to fix itself.

In my piece from last month, I also argued that the filibuster rules in the Senate allow for the continuation of poor management and governance. If weak appointed personnel are causing policy problems, communication miscues, and other headaches for the president, the ability to replace them with something other than the word “ACTING” was limited by the 60-vote threshold.

President Obama, who has faced a string of personnel and management issues over the past year, now has greater freedom not simply to oust problematic appointees, but to install talented, effective leaders. With this ability comes a tremendous opportunity to jumpstart an administration that is sputtering.

For nearly fifteen hours between Wednesday morning and early Thursday, Senator Chris Murphy (D-CT), along with his Connecticut colleague Senator Richard Blumenthal (D) and Senator Cory Booker (D-NJ), led a filibuster on the floor of the Senate aimed at addressing gun control issues in the aftermath of last weekend’s mass shooting in Orlando. Other than learning that Wednesday is pizza night in the Murphy household, what else should we take away from this Mr. Smith Goes to Washington­-style exercise? Here are three lessons:

1. The real meaning of “I” in “I hold the floor until I yield the floor.”

Anyone who tuned into yesterday’s filibuster joined Senate procedure wonks (and faithful viewers of the West Wing) in the knowledge that a senator who holds the floor can yield to another senator for a question without yielding the floor. Indeed, 38 of Murphy’s 45 Democratic colleagues (as well as two Republicans, Senators Ben Sasse (R-NE) and Pat Toomey (R-PA)), came to the chamber yesterday to ask “questions.” In many cases, these were lengthy speeches—Senator Tammy Baldwin (D-WI), for example, read brief biographies of all 49 Orlando victims—in which the speaker satisfied the question requirement with a conclusion that asked Murphy for his reactions to their statement.

This kind of teamwork on extended speech-making is not unusual. When Senator Ted Cruz (R-TX) took the floor to talk for 21 hours about the Affordable Care Act in 2013, he took questions from nine fellow Republicans (as well as two Democrats). Last May, Senator Rand Paul (R-KY) got an assist from ten colleagues, including seven Democrats, during his filibuster of a bill extending the PATRIOT Act. The depth of Murphy’s bench not only reduced the energy he had to expend speaking, but also helped guarantee that the entire discussion was on-message and focused on the topic at hand; Murphy did not have to resort to reading the phone book to fill the hours.

2. In policy terms, it’s hard to know if the filibuster was a success…

When Murphy left the floor early Thursday morning, it was reported that Senate leaders had agreed to consider two gun control amendments: one that would address the ability of suspected terrorists to purchase guns and a second that would expand background checks for gun purchases. Details of the deal ensuring consideration are still emerging, but it is difficult to know if Murphy’s filibuster caused Senate leaders to agree to hold votes on them. It is possible that, had Democrats simply threatened to object to the motion to proceed to debate on the underlying spending bill, Republican leaders would have been forced to agree to consider the amendments for which Murphy and his allies were pushing. In the contemporary Senate, this is often how obstruction proceeds: without extended speeches and off the floor, with the two sides negotiating behind the scenes.

3. …but the political victory is perhaps more important

As my colleague Sarah Binder and her co-author Steve Smith wrote in their 1997 book on the filibuster, “encouragement from external groups…has given senators an incentive to exploit their procedural rights, sometimes leading them to block legislation with the filibuster or with holds and at other times leading them to use procedural prerogatives to force the Senate to consider issues of importance to parochial, partisan, or national constituencies.” On these grounds, Murphy’s filibuster was unequivocally a success in the eyes of its supporters. As the filibuster neared its end, Murphy reported that his office had received 10,000 phone calls supporting his efforts, and the hashtag #filibuster was trending on Twitter for much of the day. Even if the underlying amendments are not adopted—a real possibility that Murphy acknowledged in one of his final speeches of the evening—the visibility of the exercise is likely to pay political dividends for Democrats in the coming weeks.

Amy Liu’s recent paper, “Remaking Economic Development,” is disruptive in that it rightfully undercuts the shaky foundation of what draws many practitioners to the field: the idea that success is simply structuring transactions to attract new jobs and investment. These two metrics alone can’t diagnose the economic health or trajectory of a community. Instead, as the paper outlines, setting the right goals—measured by growth, prosperity, and inclusion—provides a much richer framework for a community’s trajectory, vibrancy, and opportunity.

Goal-setting clarifies how a community defines success and when it has been achieved, and promotes collaboration and increases buy-in from diverse stakeholders. If, as Liu argues, goals were designed to lead to growth, prosperity, and inclusion, metro areas would make dramatically different choices around policies, investments, and priorities, and people and communities would likely be in an overall stronger economic position.

However, these goals represent a longer-term proposition than conventional measures, and, perhaps naively, “Remaking Economic Development” fails to acknowledge the barriers that prevent most communities from setting the right goals:

1. Goals should focus on long-term interests, but election cycles prioritize clear near-term political wins. Meaty investments in infrastructure, workforce development, and fiscal policy reform needed to shift the competitive position of a community rarely yield easily defined and clearly increased short-term political capital.
2. Economies function as regions, but many municipal strategies are not aligned with regional goals. A metropolitan area is the logical unit to measure success, but civic leaders are elected from individual municipalities, or from a state that has a larger focus. Although it’s easier to market a region of 5 million people than a city of 650,000, in Detroit, intramural competition between cities and suburbs, suburbs and suburbs, and even neighborhoods within the city all undermine the cooperative effort to set goals regionally. The failure of mayors within a region to recognize their economic connectedness is a huge problem and fuels wasteful incentive battles over retail and other projects that are not economic drivers.
3. Goal-setting takes time, money, and requires data, but capacity is in short supply. Most economic developers and political leaders lack the framework, experience, and manpower to effectively lead a goal-setting process. And if the choice is between collectively setting goals or managing a flurry of “bird-in-hand” transactions, the transaction under consideration will always receive resources first. Leaders are primarily evaluated on near term jobs and investment figures; not having the time to lead a goal-setting process and, in many cases, lacking the approach and datasets to appropriately undertake this activity make goal-setting easy to eliminate.

Despite these obstacles, setting the right goals is critical to building healthy communities. To combat political challenges, strong collaboration between business and public sector leadership is crucial, as is the recognition of diverse sub-economies with different value propositions and opportunities. Leaders must ultimately acknowledge that near term wins mean little if they are leading down a path that will not fundamentally address the long-term investment climate and the region’s productive capacities, grow wages or address employment levels, and offer broad opportunities for diverse economic participation. The following steps can help:

1. Harness diverse, cross-sectoral perspectives. Fundamentally, businesses understand their industries better than anyone else; hence the public sector should identify ways to encourage growth, increased productivity, greater inclusion, and more competitiveness in targeted sectors by listening to businesses and jointly setting goals that marry private sector profit and public economic and social interests effectively. This approach may offset some of the other realities of short election cycles and limited capacity to participate in goal-setting or planning processes.
2. Identify unique roles for communities within a larger regional framework. Although competition between local cities may inhibit the most meaningful dialogue and alignment of interests, deeper analysis often produces greater clarity on the niche opportunities for different communities. For example, although Detroit has a strong manufacturing base, a major project requiring more than 40 acres will likely have better site options in the suburbs. In the same vein, companies seeking a vibrant urban campus with easy access to food, living, and other amenities are likely better suited to Detroit than one of the surrounding communities. That said, both companies are likely to draw employees from communities all over the region. Effective goal-setting includes analysis that should allow municipalities to uncover their niche opportunities within a larger regional framework.
3. Balance short-term and long-term priorities and successes. The truth is that near term investments are vital in creating momentum, providing stability, and creating jobs while long-term investments, policy decisions, and industry-focused asset development fundamentally position an economy to win over time. For example, incentives play an important role in offsetting competitive disadvantages in the short-term and should be used as a way to fill the gap while a community fixes the bigger economic challenges, ranging from exorbitant development costs to workforce development issues. The disconnect is that many communities are not focusing incentives on strategic, long-term priorities.

"Remaking Economic Development” elegantly exposes the shortsightedness toward aggressive deal-making that often prevents communities from thoughtfully building their long-term economic strength with an eye on growth, prosperity, and inclusion. Sadly, the economic development profession has historically focused on growth without much attention to prosperity and inclusion, which are arguably most important in building a sustainable economy. Goal-setting—painful as it may be—is the first step towards remaking the practice and establishing an honest foundation to build a better economy in the future.

Editors’ Note: We need to do better with the long-term instruments of counterterrorism, write Raymond Odierno and Michael O’Hanlon. That includes efforts within our own societies to promote social cohesion. This article originally appeared on USA Today.

In the aftermath of the Brussels tragedy, many good ideas are being floated to improve defenses against terrorists who are poised to strike. Belgium needs more resources for police work, including staking out suspects. Europe needs terrorist watch lists that are better automated and integrated. Police forces and national intelligence agencies need to work together more effectively, readjusting the point at which traditional police work ends and counterterrorism raids begin. We need to use technology such as closed-circuit TV, as well as simpler but time-tested methods like bomb-smelling dogs, more effectively in unhardened public places like subway stops and the external lobbies of airports.

The above are immediate and short-term measures. They are crucial. They are also insufficient. We need to continue to go after Islamic State's finances, too, leading a worldwide effort to restrict its sources of revenue and ability to store and move funds around. Beyond these actions, we need to do better with the long-term instruments of counterterrorism. These include the use of social media and other counter-messaging against the so-called caliphate. But they also include efforts within our own societies and especially those in Europe to promote social cohesion. Within many countries the inability to develop programs encouraging assimilation of immigrants, and of the home-born disaffected, has led to substantial pockets of disenfranchised citizens, a large majority being Muslim.

At least on issues concerning Muslim-majority communities, the United States can help point the way. We are fortunate, largely to the credit of our nation's Muslims who join our society in full and pursue the American dream, to have relatively few problems with Islamist extremism. Of course, there are exceptions, but on the whole, Muslim-American communities are our single greatest domestic allies in the struggle against extremism at home. They help provide information on would-be terrorists in their midst; they do not typically shelter, aid or condone the thinking of such extremists. Most of all, acting as loyal citizens, they provide role models and hopeful visions to their young, reducing the odds that the 20-somethings who seem to wind up the main culprits in most attacks abroad will feel the same urge within the United States. Because our own terror watch lists have gotten better since 9/11, and because of the hard work of border and immigration agencies, we are also often able to limit the movements of suspected terrorists to the United States from abroad.

None of this is to sound complacent. More than 70 individuals were arrested on American soil last year on suspicion of interest in supporting Islamic State or otherwise conducting extremist activity, and we suffered the San Bernardino tragedy.

Beyond matters of culture and assimilation, specific programs here contribute as well. In Montgomery County, Maryland, a coalition of faith leaders, school officials and law enforcement officers collaborate to try to identify and help would-be radicals before they turn to dangerous ways. In Ohio, fire departments try to reach into difficult neighborhoods and recruit workers. They recognize that their role in society can be less polarizing to some disaffected than would, say, certain types of police outreach, but that by extending the presence of the government into places where it is not always welcome, they can tamp down the temptations of some to turn to violence.

Many places in Britain are doing the same thing. Britain is a sort of bridge to Europe on this issue, like on many others—not having the apparent problems of say Molenbeek, the enclave in Brussels from which recent attackers have originated, but also having more concentrations of recent immigrants from the Middle East than does the United States. Aware of this situation, British authorities also try to extend the state's connections with shaky neighborhoods in ways that seek to engender trust in the state and better community rapport. Sometimes this can rely on police, who in the United Kingdom are usually unarmed. However, at other times, less traditional instruments, or less potentially imposing symbols of state authority, can be better. Again, fire departments come to mind, as do work programs that foster a sense of community involvement and cohesion (while also providing a paycheck). Sometimes armies can help, depending on their roles and reputations in given societies. Any of these can improve the government's image in key neighborhoods, while also helping create the kinds of communications between community leaders and authorities that produce intelligence leads when things start to go off the tracks.

U.S. presidential candidates are not talking much about these kinds of issues. But efforts to build social cohesion are not at odds with what some of them are advocating in response to Brussels. Greater police presence in jurisdictions like Molenbeek, intelligence surges and reforms, and also stronger actions against Islamic State in the Middle East and beyond are needed, to be sure. But such measures are not, in themselves, adequate.

Building social cohesion is difficult, of course, and often the strides forward are slow to come and hard to measure. It usually must happen at the city level. It is usually manpower-intensive work. It is always painstaking. Sometimes, of course, it simply fails. But without a reinvigorated emphasis on building social cohesion, in which cities and other jurisdictions learn from each other and share best practices to tie their communities more strongly together, we will not succeed in this crucial challenge of our times.

In the face of seemingly weekly terrorist attacks and reports that Islamic State affiliates are growing in number, political leaders are under pressure to take tougher action against ISIS and other violent extremist threats. Removing terrorists from the battlefield and from streets remains critical—President Obama announced last week that the United States will send 250 more special operations forces to Syria, for one, and other military, intelligence, and law enforcement efforts will be important. According to one assessment, the United States has spent $6.4 billion on counter-ISIS military operations since August 2014, with an average daily cost of $11.5 million. As a result of these and related efforts, the territory the Islamic State controls has been diminished and its leadership and resources degraded.

The more challenging task, however, may be preventing individuals from joining the Islamic State or future groups in the first place and developing, harnessing, and resourcing a set of tools to achieve this objective. Violent extremism is most likely to take root when communities do not challenge those who seek to radicalize others and can’t offer positive alternatives. Prevention is thus most effectively addressed by the communities themselves—mayors, teachers, social workers, youth, women, religious leaders, and mental health professionals—not national security professionals, let alone national governments. But it’s easier said than done for national governments to empower, train, and resource those communities. 

Political leaders around the globe are increasingly highlighting community engagement and the role of communities more broadly in a comprehensive counterterrorism strategy. States, however, continue to struggle with how to operationalize and sustain these elements of the strategy. 

Show us the money

First, there is the funding shortfall. Too many national governments continue not to provide local governments and communities with the resources needed to develop tailored community engagement programs to identify early signs of and prevent radicalization to violence. To take just one example of the disparity, the $11.5 million per day the United States spends on its military presence in Iraq is more than the $10 million the Department of Homeland Security was given this year to support grassroots countering violent extremism (CVE) efforts in the United States, and nearly twice as much as the State Department’s Bureau of Counterterrorism received this year to support civil society-led CVE initiatives across the entire globe. Although a growing number of countries are developing national CVE action plans that include roles for local leaders and communities, funding for implementation continues to fall short. Norway and Finland are two notable examples, and the situation in Belgium was well-documented following the March attacks in Brussels.

Prevention is thus most effectively addressed by the communities themselves...not national security professionals, let alone national governments.

At the international level, the Global Community Engagement and Resilience Fund (GCERF)—established in 2014 and modeled on the Global AIDS Fund to enable governments and private entities to support grassroots work to build resilience against violent extremism—has struggled to find adequate funding. GCERF offers a reliable and transparent mechanism to give grants and mentoring to small NGOs without the taint of government funding. Yet, despite the fact that “CVE” has risen to near the top of the global agenda, GCERF has only been able raise some $25 million from 12 donors—none from the private sector—since its September 2014 launch. This includes only $300,000 for a “rapid response fund” to support grassroots projects linked to stemming the flow of fighters to Iraq and Syria—presumably a high priority for the more than 90 countries that have seen their citizens travel to the conflict zone. The GCERF Board just approved more than half of the $25 million to support local projects in communities in the first three pilot countries—Bangladesh, Mali, and Nigeria. GCERF’s global ambitions, let alone its ability to provide funds to help sustain the projects in the three pilots or to support work in the next tranche of countries (Burma, Kenya, and Kosovo) are in jeopardy unless donors pony up more resources to support the kind approach—involving governments, civil society, and the private sector—that is likely needed to make progress on prevention over the long-term.

Go grassroots

Second, national governments struggle with how best to involve cities and local communities. Governments still have a traditional view of national security emanating from the capital. Although a growing number of governments are encouraging, and in some cases providing, some resources to support city- or community-led CVE programs, they have generally been reluctant to really bring sub-national actors into conversations about how to address security challenges. Some capitals, primarily in Western Europe, have created national-level CVE task forces with a wide range of voices. Others, like the United States, have stuck with a model that is limited to national government—and primarily law enforcement—agencies, thus complicating efforts to involve and build durable partnerships with the local actors, whether mayors, community leaders, social workers, or mental health officials, that are so critical to prevention efforts. 

Some members of the target communities remain skeptical of government-led CVE initiatives, sometimes believing them to be a ruse for intelligence gathering or having the effect of stigmatizing and stereotyping certain communities. As debates around the FBI’s Shared Responsibilities Committees show, there are high levels of mistrust between the government—particularly law enforcement—and local communities. This can complicate efforts to roll out even well-intentioned government-led programs aimed at involving community actors in efforts to prevent young people from joining the Islamic State. The trouble is, communities are largely dependent on government support for training and programming in this area (with a few exceptions). 

To their credit, governments increasingly recognize that they—particularly at the national level—are not the most credible CVE actors, whether on- or off-line, within the often marginalized communities they are trying to reach. They’re placing greater emphasis on identifying and supporting more credible local partners, instead, and trying to get out of the way. 

Invest now, see dividends later

On the positive side of the ledger, even with the limited resources available, new (albeit small-scale) grassroots initiatives have been developed in cities ranging from Mombasa to Maiduguri and Denver to Dakar. These are aimed at building trust between local police and marginalized groups, creating positive alternatives for youth who are being targeted by terrorist propaganda, or otherwise building the resilience of the community to resist the siren call of violent extremism. 

Perhaps even more promising, new prevention-focused CVE networks designed to connect and empower sub-national actors—often with funds, but not instructions, from Western donors—are now in place. These platforms can pool limited resources and focus on connecting and training the growing number of young people and women working in this area; the local researchers focused on understanding local drivers of violent extremism and what has worked to stem its tide in particular communities; and mayors across the world who will gather next month for the first global Strong Cities Network summit. Much like GCERF, these new platforms will require long-term funding—ideally from governments, foundations, and the private sector—to survive and deliver on their potential. 

Somewhat paradoxically, while the United States (working closely with allies) has been at the forefront of efforts to develop and resource these platforms overseas and to recognize the limits of a top-down approach driven by national governments, similar innovations have yet to take root at home. More funding and innovation, both home and abroad, can make a huge difference. For example, it could lead to more community-led counter-narrative, skills-building, or counselling programs for young people at risk of joining the Islamic State. It could also help build trust between local police and the communities they are meant to serve, lead to more training of mainstream religious leaders on how to use social media to reach marginalized youth, as well as empower young filmmakers to engage their peers about the dangers of violent extremism. And national prevention networks that aren’t limited to just government officials can help support and mentor communities looking to develop prevention or intervention programs that take local sensitivities into account. Without this kind of rigorous effort, the large sums spent on defeating terrorism will not pay the dividends that are badly needed. 

In March alone, at least nine cities across three continents were hit by terrorist attacks. Municipalities—from megacities to tertiary cities—continue to bear the brunt of such attacks: in the short term, they provide first response and take essential security measures; in the longer term, they suffer from the fallout of intercommunal tensions and economic slowdowns, which can last for years and spread beyond the target city.

Yet, post-attack discussions tend to be dominated by what national governments can do to prevent future attacks—whether through enhanced border security, law enforcement, intelligence, or military measures; or though intensified efforts to resolve underlying conflicts; or through more cooperation with foreign governments. This is understandable given the resources of national governments and their long-standing monopoly on force and foreign policy. Nevertheless, a small but growing number of cities and other local authorities are realizing that they have an essential role to play in countering violent extremism (CVE) as well.

Urban trend-setters

There is nothing new about cities coming to the realization that they need to act in the face of global challenges. Mayors and city-networks such as the C40 Climate Action Leadership Group have vocally engaged on the global stage to counter carbon emissions. Cities have frequently shown themselves to be generally more nimble and less averse to risk-taking than their national counterparts. Mayors operate under intense expectations to “get things done,” but when it comes to the threats of transnational violent extremism, what does that mean?

Much like with climate change and other global challenges where cities are becoming increasingly active stakeholders, cities are serving as laboratories for developing and testing innovative initiatives to prevent violent extremism from taking root, designed and implemented in collaboration with local communities. 

[C]ities are serving as laboratories for developing and testing innovative initiatives to prevent violent extremism from taking root.

The comparative advantages of local authorities are manifold: They are best positioned to understand the grievances that might make their citizens vulnerable to terrorist recruitment; to identify the drivers and early signs of violent extremism; to build trust between the community and local police; to develop multi-agency prevention efforts that involve families, community leaders, social workers, and mental health professionals; and to develop programs that offer alternatives to alienated youth who might otherwise be attracted to violence. 

Recognizing these advantages, local leaders are developing strategies and programs to address the violent extremist threat at each stage of the radicalization cycle. Cities across Europe have been at the forefront of these efforts, with Aarhus, Denmark often cited as a model. The approach of Aarhus involves both prevention and care, relying an extensive community-level network to help young people returning from Syria an opportunity to reintegrate in Danish society (provided they haven’t committed a crime) and mentoring to try to dissuade people from traveling to the conflict. 

In Montgomery County, Maryland, the county authorities are involved in a community intervention program that includes training for faith leaders, teachers, social service providers, police, and parents on how to recognize the early signs of extremism in underserviced immigrant communities. 

In Montreal, a $2 million, multi-disciplinary “anti-radicalization center” provides mothers who suspect their children may be vulnerable to radicalization or recruitment with resources that don’t involve contacting the police. The center focuses on training people how to identify the signs of radicalization and researching the drivers of radicalization in Montreal and what works to prevent its growth. 

Cities are dynamic actors, in part, because they have no problem borrowing from each other. Inspired by the Montreal initiative, Brussels opened a prevention-focused, anti-radicalization center, which—like the Montreal center—keeps the police out of the picture unless necessary to confront an imminent threat.

In Australia, both Victoria and New South Wales have set aside funds to support local NGO-led interventions that target individuals who may be radicalizing and build community resilience.

In Mombasa, Kenya, Governor Hassan Ali Joho is working with the regional parliament and local civil society groups to develop a county-level CVE strategy that includes a heavy focus on providing youth with positive alternatives to joining al-Shabab.

Except for Mombasa, nearly all municipality-led CVE efforts are taking place in the global north. Throughout the world, mayors and other local leaders are not part of national-level conversations about how to prevent future attacks. If national governments insist on viewing national security issues like violent extremism as being the exclusive policy domain of the capital, they will miss crucial opportunities to address a threat that is increasingly localized. 

Part of the challenge is that, much like on other global issues, municipal authorities operate within the policy and bureaucratic frameworks of national governments. Those governments can enable or, just as frequently, impede effective local action. Thus, there is often a ceiling for local actors. Raising or breaking through the ceiling is particularly difficult in the security space, given the monopoly that many national governments want to maintain over issues of national security—even while recognizing the need for local solutions.

Flattening the CVE policy space

The good news is that in countries where local authorities can innovate and lead, energy around city-led CVE efforts is increasing. Cities are sharing lessons learned and challenges, with city-to-city networks like with the Strong Cities Network (SCN)—which held its first summit earlier this month in Antalya, Turkey—sprouting to facilitate cooperation.

Yet, a significant majority of SCN members are in countries where national governments already acknowledge local authorities’ key role in CVE. With a few exceptions, cities from large swathes of the globe—including in regions where the problem of violent extremism is most acute, like the Middle East and North Africa, as well as Asia—are not enabled to contribute to efforts to prevent violent extremism from taking root in their communities. 

CVE discussions in general should highlight ways in which national policymakers have enabled effective local CVE activities, as well as roadblocks and solutions. These discussions should also be brought into multilateral platforms such as the U.N. Global Counterterrorism Forum. 

A number of other steps could be taken to enhance vertical cooperation on CVE. For example, countries could involve municipal-level representatives (not simply the national ministry responsible for engaging with such authorities) in developing national CVE plans and provide such authorities with a role in implementation. National governments that already do this could start including representatives of cities in security and broader foreign policy dialogues, particularly with those that continue to resist their involvement. 

National governments should incentivize local authorities to work with their communities to innovate in this issue area. A public-private innovation fund could be established to support city-led CVE projects in countries where political will exceeds resources; those international donors committed to supporting local solutions to global challenges and increasing the involvement of local authorities in national security conversations should invest in such a fund and, more broadly, in building the capacity of city-level officials and practitioners in the CVE sphere.

None of these steps is likely to be an elixir—after all, the notion that national security issues should be handled exclusively at the national level is deeply entrenched. However, taking these steps can generate gradual improvements in vertical cooperation on CVE issues, much like we have seen with international and inter-agency counterterrorism cooperation involving national governments over the past decade.