Led by presidential candidate Bernie Sanders, one-time supporters of ‘single-payer’ health reform are rekindling their romance with a health reform idea that was, is, and will remain a dream.  Single-payer health reform is a dream because, as the old joke goes, ‘you can’t get there from here.

Let’s be clear: opposing a proposal only because one believes it cannot be passed is usually a dodge.One should judge the merits. Strong leaders prove their skill by persuading people to embrace their visions. But single-payer is different. It is radical in a way that no legislation has ever been in the United States.

Not so, you may be thinking. Remember such transformative laws as the Social Security Act, Medicare, the Homestead Act, and the Interstate Highway Act. And, yes, remember the Affordable Care Act. Those and many other inspired legislative acts seemed revolutionary enough at the time. But none really was. None overturned entrenched and valued contractual and legislative arrangements. None reshuffled trillions—or in less inflated days, billions—of dollars devoted to the same general purpose as the new legislation. All either extended services previously available to only a few, or created wholly new arrangements.

To understand the difference between those past achievements and the idea of replacing current health insurance arrangements with a single-payer system, compare the Affordable Care Act with Sanders’ single-payer proposal.

Criticized by some for alleged radicalism, the ACA is actually stunningly incremental. Most of the ACA’s expanded coverage comes through extension of Medicaid, an existing public program that serves more than 60 million people. The rest comes through purchase of private insurance in “exchanges,” which embody the conservative ideal of a market that promotes competition among private venders, or through regulations that extended the ability of adult offspring to remain covered under parental plans. The ACA minimally altered insurance coverage for the 170 million people covered through employment-based health insurance. The ACA added a few small benefits to Medicare but left it otherwise untouched. It left unaltered the tax breaks that support group insurance coverage for most working age Americans and their families. It also left alone the military health programs serving 14 million people. Private nonprofit and for-profit hospitals, other vendors, and privately employed professionals continue to deliver most care.

In contrast, Senator Sanders’ plan, like the earlier proposal sponsored by Representative John Conyers (D-Michigan) which Sanders co-sponsored, would scrap all of those arrangements. Instead, people would simply go to the medical care provider of their choice and bills would be paid from a national trust fund. That sounds simple and attractive, but it raises vexatious questions.

• How much would it cost the federal government? Where would the money to cover the costs come from?
• What would happen to the $700 billion that employers now spend on health insurance?
• How would the $600 billion a year reductions in total health spending that Sanders says his plan would generate come from?
• What would happen to special facilities for veterans and families of members of the armed services?

Sanders has answers for some of these questions, but not for others. Both the answers and non-answers show why single payer is unlike past major social legislation.

The answer to the question of how much single payer would cost the federal government is simple: $4.1 trillion a year, or $1.4 trillion more than the federal government now spends on programs that the Sanders plan would replace. The money would come from new taxes. Half the added revenue would come from doubling the payroll tax that employers now pay for Social Security. This tax approximates what employers now collectively spend on health insurance for their employees...if they provide health insurance. But many don’t. Some employers would face large tax increases. Others would reap windfall gains.

The cost question is particularly knotty, as Sanders assumes a 20 percent cut in spending averaged over ten years, even as roughly 30 million currently uninsured people would gain coverage. Those savings, even if actually realized, would start slowly, which means cuts of 30 percent or more by Year 10. Where would they come from? Savings from reduced red-tape associated with individual insurance would cover a small fraction of this target. The major source would have to be fewer services or reduced prices. Who would determine which of the services physicians regard as desirable -- and patients have come to expect -- are no longer ‘needed’? How would those be achieved without massive bankruptcies among hospitals, as columnist Ezra Klein has suggested, and would follow such spending cuts? What would be the reaction to the prospect of drastic cuts in salaries of health care personnel – would we have a shortage of doctors and nurses? Would patients tolerate a reduction in services? If people thought that services under the Sanders plan were inadequate, would they be allowed to ‘top up’ with private insurance? If so, what happens to simplicity? If not, why not?

Let me be clear: we know that high quality health care can be delivered at much lower cost than is the U.S. norm. We know because other countries do it. In fact, some of them have plans not unlike the one Senator Sanders is proposing. We know that single-payer mechanisms work in some countries. But those systems evolved over decades, based on gradual and incremental change from what existed before. That is the way that public policy is made in democracies. Radical change may occur after a catastrophic economic collapse or a major war. But in normal times, democracies do not tolerate radical discontinuity. If you doubt me, consider the tumult precipitated by the really quite conservative Affordable Care Act.

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

As I’ve noted in a previous JAMA Forum post, there has been a determined and serious effort in recent years by a broad range of organizations and analysts to find a consensus approach to the growing problem of financing long-term care in the United States. These efforts have just resulted in 2 major reports, released in February.

One report comes from the Bipartisan Policy Center (BPC), a national think tank committed to finding workable bipartisan policy solutions. The other is published by the Convergence Center for Policy Resolution, an organization that convenes groups and individuals with conflicting views to seek consensus on difficult issues. Participants in the latter project, known as the Long-Term Care Financing Collaborative, included leaders from major think tanks and philanthropy, insurance associations, health and consumer advocacy groups, organizations representing the interests of older Americans, not-for-profit services, and care for elderly persons, as well as former state and federal officials. (Disclosure: I served as an advisor to the BPC project and as a member of the Collaborative).

It’s a big step forward that the diverse participants in each of these projects were able to come to agreement. Why was that possible?

For one thing, the huge cost of long-term care and earlier failures to agree clearly focused many minds. Future costs are indeed attention-grabbing. Over the next 40 years, for instance, the number of elderly US residents with a severe need for long-term services and supports (LTSS) will increase 140% to more than 15 million. Meanwhile US adults turning 65 today can expect to incur an average of $138 000 in LTSS costs. But there is a wide risk distribution, with 15% of these seniors likely incurring more than $250 000 in expenses. Meanwhile, private insurance that covers the most crippling potential costs is proving harder and harder to find, with insurers increasing premiums and most pulling out of the market—in part because of the heavy and less predictable costs of aging.

Another factor that helped agreement in these projects was that the Urban Institute was able to upgrade its dynamic simulation model and to partner with the actuarial firm Milliman to incorporate claims data into its research to provide far more sophisticated and reliable estimates of several benchmark proposals. Urban made its model available to a range of organizations, including BPC (an employee benefits consulting company), LeadingAge (an association of groups that offer aging-related services), and the Collaborative. The estimates the Urban Institute produced had the effect of narrowing the set of plausible components in any serious plan. For instance, it became clear that a voluntary public catastrophic insurance program—even with subsidies—would be hard-pressed to significantly boost the number of people acquiring insurance protection against catastrophic LTSS costs.

What’s also important about these 2 projects is that the reports agree on several key elements. These elements are likely to form the core of potentially bipartisan legislation under a new Congress and administration. Among the most important are:

• Improving the market for private insurance. The BPC and the Collaborative proposals call for a number of steps to revitalize the market for private long-term care insurance, such as allowing employment-based retirement savings to be used for premiums and perhaps using autoenrollment to increase the take-up of available coverage. Both plans propose simpler, more standardized plans, with BPC including details of standard options. The Collaborative recommends clearly delineating private and public roles in long-term care insurance, with a stronger public role in addressing high need, long duration risk. As a further step toward bolstering the insurance market, both proposals recommend exploring innovations in long-term care product design. Ideas include possible jointly marketed products with health insurance or Medicare and perhaps long-term care coverage combined with life insurance or annuities.
• Public catastrophic insurance. Both reports call for a public catastrophic program for individuals with extraordinary costs to protect them from poverty and bankruptcy. In part, this is also to help cover the “tail end” risk that discourages private insurers from offering comprehensive protection, thereby allowing insurers to focus on shorter-term, more predictable coverage.  Each report is cautious about the uncertain cost of such protection but notes that the Medicaid program currently plays the role of insurer of last resort, and so a new catastrophic long-term care insurance program could help shift from the current welfare-based model toward a system of insurance. Echoing this, a new report from LeadingAge, which represents thousands of organizations engaged in aging services, also concluded that a universal program appears the best way to handle catastrophic costs.
• Retooling Medicaid. Both reports call for revamping Medicaid, by retooling its LTSS component to better serve persons with disabilities and others with long-term needs. Under both the BPC and Collaborative plans, states would offer a sliding-scale “buy-in” for Medicaid’s LTSS benefits. For working individuals with disabilities, this would function as a wraparound service to employer-sponsored health insurance and other health coverage. As both reports point out, the public catastrophic long-term care program would produce some savings for state Medicaid programs, making it financially easier for states to offer the wraparound coverage.
• Home and community based services. The 2 reports emphasize the importance of fostering community-based care and helping family caregivers.  An AARP report found that approximately 34 million family members and friends—mainly women—provide unpaid care to an older adult each year. The BPC would streamline waivers from federal rules to encourage states to expand home and community services. The Collaborative takes a step further and recommends entirely redefining Medicaid LTSS to include all settings and services currently offered under “mandatory” and “optional” state programs, and by doing so, eliminating the current bias in financing toward institutional care. The BPC suggests exploring some support for these caregivers, including temporary respite care to allow the usual caregiver some time off. The Collaborative published a report last summer, arguing for much greater integration of health and LTSS, including housing and transportation and for greater opportunities for training and support for caregivers.

There is of course a long road between publishing recommendations and the passage of legislation. And there are gaps in these proposals. For instance, how much a full proposal would cost and how it would be paid for (including how much from savings or new taxes) depends on design choices not worked out in detail.

But the similarity of these reports, the range of people and organizations involved and the determination of the participants to find common ground are in stark contrast to the polarization and gridlock we have become accustomed to. It augers well for enacting a solution to the enormous challenge of long-term care costs.

Editor's note: This piece originally appeared in The JAMA Forum

Editor's note: On March 1, Alice Rivlin testified before the U.S. House of Representatives Committee on Energy and Commerce Subcommittee on Health on the financing and delivery of long-term care in the US. 

Chairman Pitts, Ranking Member Green: I am happy to be back before this Subcommittee, which is never afraid to take on complex issues of great importance to millions of Americans. I have worked on long-term services and supports (LTSS) for a long time and have recently had the privilege of co-chairing the Long-Term Care Initiative at the Bipartisan Policy Center (along with former Senators Bill Frist and Tom Daschle and former Governor and Secretary of Health and Human Services, Tommy Thompson). Our February 2016 report, Initial Recommendations to Improve the Financing of Long-Term Care, appended to my testimony, outlines a set of doable, practical changes in both public and private programs that could improve the availability and affordability of long-term services and supports.

I don’t need to remind this committee that Americans are living longer, and many of us will need help with the ordinary activities of daily living and suffer cognitive impairments that make it dangerous for us to cope alone. The number of people needing LTSS is rising and expected to double in the next 35 years or so.

Responsibility for LTSS is shared among seniors and people with disabilities themselves, family, friends, and volunteer care-givers; communities, state, and federal government. This shared-responsibility system is severely stressed, and will become increasingly unable to cope as the numbers needing care increase. Growing burdens fall on families, often daughters and daughters-in-law, who must manage daily conflicts between earning a living, caring for children, and meeting the needs of elderly or disabled relatives. Growth in Medicaid, the largest payer of long-term services and supports at about $123 billion per year, stresses state and federal budgets as spending for older Americans and individuals with disabilities competes with budgets for education and other investments in young people.

Many efforts to find a comprehensive solution to long-term care financing have failed—evidenced by passage and subsequent repeal of the Community Living Assistance Services and Supports (CLASS) Act and failure of the federal Long-term Care Commission to reach consensus on financing recommendations. Recently, however, a growing consensus has emerged around a set of incremental steps, which, if taken together could greatly improve the availability and affordability of long-term services and supports to America’s most vulnerable populations and take some of the burden off families and Medicaid in a fiscally responsible way. In recent weeks, The Bipartisan Policy Center and The Long-term Care Collaborative have offered similar sets of recommendations, as has LeadingAge, a key provider association.

While policymakers failed to agree on big legislative solutions, amazing progress has been made at the community level in finding new ways of keeping older Americans and people with disabilities out of institutions and in the community where they are happier and less isolated and can be served more effectively and cheaper. There has been an explosion of assisted living facilities, continuing care communities, senior villages, senior centers, senior daycare, and use of home health aides of various sorts. Growth in home and community-based services (HCBS) has been rapid, while the population served by traditional nursing homes has been virtually flat. Medicaid, with the support of both parties in Congress, has moved to increase the availability of home and community-based services.

The group working on the Bipartisan Policy Center’s Long-Term Care Initiative addressed the question: Is there a set of practical policies that could command bipartisan support that would improve the care of older Americans with disabilities, take significant pressure off families and Medicaid, and not break the bank? We came up with four proposals.

Make private long-term care insurance more affordable and available. Long term care ought to be an insurable risk. If more people bought Long-Term Care Insurance (LTCI) in their earning years, there would be less pressure on their savings and family resources and Medicaid when they became disabled. But both demand and supply of LTCI are weak and falling. Potential customers are reluctant to buy because it is costly and the need seems remote and hard to think about. Carriers find it difficult to price a product that will be used far in the future and fear losing money if customers live and use services for a long time. Many insurance companies have stopped offering LTCI.

Our report recommends developing a new type of private insurance product: “retirement long-term care insurance,” which would cover long-term care for a limited period (2-4 years) after a substantial deductible or waiting period and would have coinsurance. The insurance would provide inflation protection, which helps to ensure benefits keep pace with the rising costs of care, and a non-forfeiture benefit, which allows lapsed policyholders to access a limited benefit. Employers would be encouraged to offer such policies as a default option as part of a retirement plan. These policies, if offered through employers and public and private insurance exchanges, could cut premiums in half according estimates done by Milliman, LLC, for the Bipartisan Policy Center and other organizations. Penalty-free withdrawals would be allowed from retirement plans, such as 401(k) plans and IRAs, beginning at age 45, exclusively for the purchase of retirement LTCI.

Design a federal long-term care insurance option for those with catastrophic costs. Part of the reluctance of carriers to offer LTCI relates to the difficulty of predicting costs far in the future and the fact that a few policy holders may have extremely high costs for a very long time. A public program, covering truly catastrophic long-term care spending, could overcome this reluctance and reduce the cost of private LTCI. Catastrophic insurance, combined with retirement LTCI from the private market, could substantially relieve families and Medicaid. The cost of this program should be fully offset so as not to add to the deficit.

Streamline Medicaid home and community-based care options to encourage more effective care in lower-cost settings. While Congress has been proactive in encouraging state Medicaid programs to shift care settings from institutions to home and community-based care, states continue to face a daunting federal waiver process and multiple state options. Securing waivers requires complex negotiations between states and the federal government, and each of the existing state options have disincentives. Home and community-based options should be simplified into a single streamlined state plan amendment process.

Ensure that working people with disabilities in need of long-term services and supports do not lose access to their long-term services and supports as earnings increase. Individuals with modest employment incomes risk losing access to services that permit them to remain on the job. Existing Medicaid “buy-in” programs are often costly. Building on the “Achieving a Better Life Experience,” or “ABLE” Act, states could be given the option to offer a lower-cost, Medicaid buy-in for long-term services and supports designed to “wrap around” private health insurance or Medicare. Under this option, working individuals with disabilities would pay an income-related, sliding-scale premium.

Mr. Chairman and members of the Committee, thank you again for the opportunity to share my thoughts on this issue. It is one of America’s big challenges, but it’s an even bigger opportunity for a constructive bipartisan policy process. I look forward to continued dialogue and will keep you apprised of forthcoming recommendations by BPC’s Long-Term Care Initiative in 2016 and 2017.

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• Download Alice M. Rivlin's full testimony

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

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

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

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

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

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

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

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

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.

Download "Shifting Away From Fee-For-Service: Alternative Approaches to Payment in Gastroenterology" »

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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.

As we explore the social determinants of health, we are discovering some very important things. One is that compared with other developed countries, the United States spends a much higher proportion of resources on medical services to treat people than on social services that improve the prospects for good health. Research shows that countries placing a greater emphasis on social services rather than medical care have better health outcomes. Recent research comparing spending on health and social services among US states also found that spending relatively more on social services is significantly related to better health outcomes.

But getting the health system to “prescribe” social services is hard. Hospitals, in particular, do not easily cooperate with social service organizations in trying to improve community health. There are many reasons for this. Institutional culture can get in the way; the health care sector’s business model is not exactly based on reducing the volume of medical services. Shifting substantial resources from medical services to social services threatens the financial interests of a major industry.

In addition, data systems of medical, educational, and social service organizations often are not compatible, and privacy concerns add to that barrier. Budget and payment systems generally don’t encourage multisector cooperation either, and community organizations often feel their independence is threatened by partnering with a large local hospital.

These problems are not unique to the health care and social services worlds. When 2 sectors seek to cooperate, the ideal is to harmonize all systems so that they can interact seamlessly. But that is an enormous task, usually requiring daunting changes for organizations in each sector.

A Role for Intermediaries

One way to enable collaboration between large institutions and sectors that find it hard to cooperate directly is to introduce intermediaries to serve as bridges. By intermediaries we mean organizations that operate in the space between institutions or people and help link them together. Successful intermediaries have the trust of each institution, and so they fulfill a “diplomatic” function. They provide skills and capacities that are lacking in the organizations they connect together. In addition to helping us achieve a better combination of medical care and social services to produce improved health, they can help health care and other sectors to work together more seamlessly.

As health care institutions seek to work with other sectors to address social determinants of health, we are beginning to see certain types of intermediaries that will be particularly helpful.

Data Intermediaries

Sharing data on patients and households is necessary to coordinate multisector services, but it also raises technical, governance, and privacy concerns. Some intermediary organizations are addressing these issues by making it easier for institutions to share data and cooperate. For instance, to make service data more available to institutions trying to work together, an initiative called Actionable Intelligence for Social Policy (AISP) works with counties and other jurisdictions to address technical and governance concerns. With the assistance of the nonprofit and nonpartisan advocacy organization Data Quality Campaign as a technical intermediary, many states and counties are tackling the privacy and other issues needed to create integrated data systems—or “data warehouses”—that can enable health systems, schools, and other sectors to coordinate services for each student. Meanwhile the National Neighborhood Indicators Partnership (NNIP) helps develop neighborhood-level data to help organizations design policy plans for addressing social and health needs.

Embedded “Extenders”

Another interesting approach is for institutions, particularly some hospitals, to bring intermediary institutions onto their premises to address social service needs for discharged patients. For instance, the nonprofit organization Health Leads trains and funds individuals to be embedded in hospitals and link patients to an array of social services and community organizations, thereby bringing skills the hospital typically does not possess in-house. Washington Adventist Hospital contracts with Seedco, a national nonprofit focused on work and family supports, to coordinate such services for its patients.

In reverse, some other institutions have an embedded staff that can link them more effectively with the health care system. School-based nurses are an example. In some states, a nonprofit organization called Communities in Schools embeds teams in schools to link students with health care services and with social service agencies that can improve their students’ health and help them succeed academically.

Budget Blenders

Restrictions on who can receive federal and state program money create funding silos that make it hard for health systems to partner with community social service organizations. A 3-track Accountable Health Communities model, which the Obama Administration will be implementing and testing over a 5-year period, may be a step towards resolving that issue. But meanwhile, some intermediaries are helping to address the problem.

One interesting example is made possible by the state of Maryland’s use of Local Management Boards (LMBs). These county-level public or nonprofit entities have the legal ability to deploy certain federal grants and programs administered by the state, as well as state resources, to local organizations with the aim of improving the health and educational success of children. In some cases the boards are governmental institutions, but in other cases, such as the Family League of Baltimore, they are intermediary organizations that coordinate and oversee funds and grantees. In this way, intermediaries that are close to the community and have trusted links with a range of health and social service organizations can help social service and health care institutions concentrate on social determinants of health.

Connectors

Some intermediaries function almost as entrepreneurs, developing creative ways to facilitate relationships between health care institutions and other sectors. The National Collaborative on Education and Health, for instance, brings together multiple organizations focused on steps to create a culture of health within schools. City Health Works, in New York’s Harlem, uses personal coaches to connect households with hospital partners and social service providers to improve health in the community.

This rich tapestry of intermediaries can help the health system collaborate more effectively and seamlessly with social services and community institutions as we focus on social determinants of health. So we can take steps to foster the use of intermediaries. For instance, states can emulate Maryland’s LMB’s, by creating county or city bodies to coordinate funding streams and steer support to innovative community organizations.

Governments and foundations can also provide the modest seed capital needed for intermediaries to develop data systems, so that they can play a more sophisticated role. The federal government can tweak the community benefit requirements for nonprofit hospitals to encourage them to invest in nonmedical services that promote health. Most important and starting at the local level, health plan administrators, health care professionals and facilities, government, school districts, and social service agencies need to sit down together to identify how to improve community health by changing patterns of spending.

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

On June 29, the Latin America Initiative (LAI) at Brookings and the Corporación Andina de Fomento (CAF) hosted a panel of experts from Latin America to discuss the significance of the renewed hemispheric partnership between the U.S. and Latin America. In this video from the event, LAI director Mauricio Cárdenas discusses the challenges of U.S. foreign policy in Latin America and how the focus has changed since President Obama took office.

Over the past decade, many observers of U.S.-Latin America relations have taken a pessimistic view, arguing that U.S. influence is in retreat and decline. In this more optimistic policy brief, Richard Feinberg, Emily Miller, and Harold Trinkunas show that—to the contrary—U.S. core interests in the region have steadily improved in recent decades. While acknowledging heartening successes in the region, the authors outline how the United States should adapt its instruments of diplomacy for the 21st century.

Key Findings

• U.S. core interests in the hemisphere are: (1) progressive, resilient political democracies with respect for human rights; (2) reasonably well-managed, market-oriented economies open to global trade and investment; (3) inter-state peace among nations; and (4) the absence of credible threats to the United States from international terrorism or weapons of mass destruction.

• In country after country, international and domestic actors have aligned to produce stronger economic growth, improved macroeconomic management, consolidated democracy, and inter-state peace.

• Traditional tools of U.S. leverage—including bilateral economic assistance, economic policy advice, sanctions, arms transfers, military training, and covert and overt military interventions—have declined dramatically in effectiveness and relevance.

• In a few countries, poor domestic policy choices have produced problematic macroeconomic outcomes and political conflict. However such cases may well be corrected as domestic politics change in due course.

Policy Recommendations

• Organize U.S. hemispheric policy around bolstering our four core interests and the regional institutions that undergird them.

• Target our policies toward Latin America to focus on collaboration on global governance with the upper-middle income countries, technical assistance for the fragile states of the Caribbean Basin, and watchful patience with rejectionist leaders as we wait for history to take its course.

• Rethink and retarget problematic U.S. counternarcotics policies, both to rebalance away from their dominance in the assistance agenda to Latin America and to focus on dimensions of the problem that fall under U.S. jurisdiction and control.

• Extend the principle of evidence-based programs, systematically evaluated based on transparent metrics, to other dimensions of our economic and security assistance to the region.

• Manage the challenges posed by our relationship with Brazil within a broader framework designed to promote constructive contributions by all rising powers to a stable and peaceful international order.

• Ensure that China’s inevitable economic presence in the region contributes positively to Latin America’s development without eroding hard-won political and social gains.

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• Better Than You Think: Reframing Inter-American Relations

On April 10th and 11th, the heads of state and government from nearly every state in the Americas will meet in Panama City for the Seventh Summit of the Americas. The leaders present in Panama preside over a region that has advanced far and fast on key political and economic indicators since the first of these meetings was held in Miami in 1994. At the Miami Summit, the legacy of the Cold War was very much present, and the specter of war, military dictatorship, armed revolution, financial crises, and political instability still hung in the air. 

In 2015, the region is by and large more democratic, economically prosperous, free from war, and the last insurgency in the region—Colombia’s—is winding down as peace is discussed between the government and its opponents at talks hosted by Havana. The beginning of a rapprochement between the United States and Cuba in December 2014 broke down one of the last remaining obstacles to an event that is truly inclusive of every country in the Western Hemisphere. 

In comparison to the rest of the world—where in the past year we have witnessed terrorist attacks in Paris, war in Ukraine, insurgency in Yemen, and saber-rattling around the South China Sea—the Western Hemisphere appears to be relatively better off. While there are a small number of countries that face challenging circumstances, especially among the fragile states of the Caribbean basin, these problems mostly threaten local rather than regional order. Given this picture, what lessons can we learn from the Western Hemisphere, and from U.S. policy towards the region, as we contemplate how best to improve global order?

Drawing the right lessons from history

The Americas have a long history of developing regional norms that promote the peaceful resolution of conflicts. Since the founding of the Panamerican Union in 1890, which transformed into the Organization of American States (OAS) in 1948, the countries of the hemisphere have embedded these norms of peace into their multilateral institutions. While frequently criticized, it is important to remember that the OAS has presided over the elimination of inter-state conflict in the Americas. 

Today, Latin American states resolve territorial disputes at the International Court of Justice rather than on the battlefield. The last war in the region, between Peru and Ecuador in 1995, occurred two decades ago. Given how rare militarized disputes are at home, Latin American soldiers frequently serve as peacekeepers in United Nations missions around the world. Latin Americans have become good at peacemaking and peacekeeping, something that other regions of the world would do well to emulate.

When it comes to domestic politics, most leaders in the region now understand the political and economic principles that contribute to stability. Governments have become much better about economic governance, which means that as South America’s economy cools off this year, fiscal problems will be manageable and localized rather than region-wide and existential, a sharp contrast with the 1980s and 1990s. 

Leaders in the region have learned that promoting polarization for short-term political advantage is all too likely to produce instability, coups, and revolution. To minimize the risk that domestic political violence might reoccur in the future, states in the region have self-consciously examined the legacy of their authoritarian pasts, using innovative processes such as truth and reconciliation commissions—initially in Argentina in 1983—but also drawing on traditional courts to prosecute perpetrators of past abuses.  

In the 21st century, successful coups d’état have become rare, and when they do occur, as was the case in Honduras in 2009, the region collaborates to ensure a return to democracy. Here again is an area where Latin America has led the way through policies that reduce the likelihood of domestic conflicts that threaten internal stability or global order.

The importance of revisiting unworkable U.S. policies 

At this Summit in Panama, President Barack Obama will be able to credibly claim that he has listened to his Latin American counterparts and has begun to change policies that had become obstacles to improving regional order. At the 2009 and 2012 Summits (they occur every three years), U.S. policies on drugs, immigration, and Cuba had made President Obama the target of growing criticism from other leaders. In fact, many governments had made it clear that they would not attend the 2015 Summit if Cuba was not invited. 

Since 2012, the Obama administration has taken steps to address these concerns. It has taken executive action to reform immigration policy, signaled greater openness to drug policy liberalization by states such as Uruguay, and initiated a historic normalization of relations with Cuba. In each of these areas, the United States has shifted from policies that were largely unilateral towards its neighbors to policies that emphasize collaboration and partnership. This reflects U.S. learning that unilateralism produces blowback, strengthens its political adversaries in the region, and undermines its interests in the long run. This is a lesson worth considering as we think about our policies towards troubled regions of the world.

The risk of forgetting lessons learned

Yet not all countries and all politicians have remembered these lessons, and some of them have learned the wrong ones. In Argentina, macroeconomic stability is at risk due to a feud between the government and its international creditors. The result is a country cut off from international capital markets at a time when its economy is suffering the effect of declining commodity prices. Venezuela faces a deep crisis that has at its heart the highly polarizing politics practiced by the governing party and an unreasoning attachment to an unworkable economic model. Key countries such as Brazil have lost interest in hemisphere-wide institutions, as indicated by their refusal to appoint an ambassador to the OAS or pay their membership dues. And the region as a whole has become so attached to multilateralism and politics by consensus that is has forgotten how to work together when individual member states deviate from regional norms of democracy and human rights, as is occurring today in Venezuela.

So while the recent history of the Americas offers insights into policies that contribute to a peaceful and stable regional order, it also illustrates that these achievements are not irreversible. Let us hope that future generations do not have the relearn these lessons anew. At this and future Summits, there must be a commitment to preserving the gains made in peace, democracy, human rights, and economic prosperity, but also a new emphasis on developing workable mechanisms to address deviations from the norms and practices that have contributed to making the Americas a relative safe and orderly region of the world.

For more information, check out Emily Miller's post on U.S. priorities at the Seventh Summit of the Americas.

At the previous Summit of the Americas in Cartagena, Colombia in April 2012, President Barack Obama was badly roughed up by his Latin American counterparts (and embarrassed by his Secret Service for entertaining sex workers). Happily, the president and his entourage did much better at last week’s Summit in Panama, but the United States still has a way to go before the Summits once again become the productive vehicle for U.S. foreign policy that they once were, at their founding in Miami in 1994.

In Cartagena, leader after leader criticized the United States for allegedly heavy-handed counter-narcotics policies; oppressive treatment of immigrants; a weak response to crime and poverty in Central America; and monetary policies that supposedly harmed their economies. Most pointedly, speakers denounced the decades-old economic sanctions against Cuba. But given the upcoming Congressional elections, Obama and his Secretary of State Hillary Clinton did not want to do anything to endanger their Democratic Party’s chances. Obama was reduced to affirming, uncharacteristically, “I am here to listen, but our policies will not change.”

Once the November 2012 mid-term elections were over, policies did, in fact, change as the United States took a more relaxed approach to counternarcotics; the administration announced immigration policy reforms, including negotiating agreements with Central American nations to reduce the outflow of children and promote economic growth and jobs at home; and Vice President Joseph Biden met repeatedly with Central American leaders, and offered $1 billion in economic and security assistance.

In Cartagena, the Latin Americans threatened to boycott the Panama Summit if Cuba was not invited. But last December 17, President Obama and Cuban President Raúl Castro announced their agreement to negotiate the normalization of diplomatic relations, and in one blow, the United States transformed a thorn in relations with Latin America into a triumph of inter-American diplomacy that significantly enhanced U.S. prestige in the region.

So in Panama, most of the Latin American and Caribbean leaders, rather than berate the U.S. president, praised him for his courage and generally treated him with courtesy and respect. The three leaders of Central America’s Northern Tier (Guatemala, Honduras, and El Salvador—whose president is a former guerrilla commander) were effusive in their praise. The president of Brazil, Dilma Rousseff, who in Cartagena had sharply criticized U.S. monetary policies and had cancelled a visit to the White House to protest NSA spying, was pleased to announce that her visit had been rescheduled for this June. 

Obama’s own performance was more spirited than it had been in Cartagena. In response to a harsh polemic by Ecuadorean President Rafael Correa, Obama shot back: “The U.S. may be a handy excuse for diverting attention from domestic political problems, but it won’t solve those problems.” After listening politely through Raúl Castro’s extended remarks—during which Castro praised him as a man of honesty and authenticity—Obama departed to avoid having to sit through the predictable harangues of Argentine President Cristina Kirchner and Bolivian leader Evo Morales. Few could blame him.

At the parallel CEO Summit of business executives, Obama delivered thoughtful responses to questions posed by several entrepreneurs including Facebook founder Mark Zuckerberg, distinguishing himself from the facile rhetorical answers of the other presidents on the panel. At a Civil Society Forum where delegates affiliated with Cuban government organizations engaged in disruptive tactics, Obama lectured firmly on the virtues of civility and tolerance. Together with two other presidents (Tabaré Vasquez of Uruguay and Guillermo Solis of Costa Rica), Obama met privately with a dozen leaders of nongovernmental organizations, took notes, and incorporated at least one of their suggestions into his later public remarks.

But Obama’s Panama experience was marred by an inexplicable misstep by his White House aides a month earlier—the very public sanctioning of seven Venezuelan officials for alleged human rights violation and corruption, and the declaration that Venezuela was a “threat to U.S. national security.” To Latin American ears, that language recalled Cold War-era justifications for CIA plots and military coups. The State Department claims it warned the White House against Latin American blowback, but perhaps not forcefully enough. Once Latin American anger become apparent, the White House tried to walk the “national security” language back, saying it was just a formality required by U.S. legislation, but the damage was done. Speaker after speaker condemned the “unilateral sanctions” and called for their repeal.

The ill-timed sanctions announcement provided Venezuelan President Nicolás Maduro and his populist allies with a ready stick to beat the United States. For whileObama’s diplomacy had managed to peel off most of the Central Americans and win over or at least diminish the antagonism of other leaders, it had not found a way to tranquilize the rejectionist states (Ecuador, Bolivia, Nicaragua, Argentina) tied to Venezuela in an “anti-imperialist” alliance. Although a relatively small minority, these spoilers seriously disrupt plenary meetings with long and vituperative monologues, and small minorities of “veto” players can block the signing of otherwise consensus documents such that in Panama, as in Cartagena, no consensus declaration was issued; rather the host leader signed brief “mandates for action” that lacked full legitimacy.

The problem of the rejectionist minority will be partially alleviated when Kirchner is shortly replaced, likely by a more moderate government in Argentina, and political turnover will eventually come in Venezuela, but the hemisphere needs new rules that protect majority rights to get things done. Some simple procedural innovations, such as a more forceful chair, or even the simple system of red-yellow-green lights that alert speakers to their time limits, would help.

Notwithstanding the misstep on Venezuela sanctions and the disruptive tactics of the rejectionist minority, the overall mood in Panama was upbeat, even celebratory. Leaders made reference to the xenophobic violence and religious intolerance plaguing other continents, and remarked with some pride that, in comparison, Latin America was a zone of peace that was also making progress, however inadequate, on human rights, poverty alleviation, and clean energy. With some procedural fixes, favorable political winds, and continued progress on concrete issues of mutual interest, inter-American relations could well continue their upward trajectory.

Read more about the Summit with Richard Feinberg's post on Cuba's multi-level strategy at the Seventh Summit of the Americas.

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.

President Barack Obama’s visit to the George Herbert Walker Bush Library in College Station, Texas this week highlights the crucial role of America’s volunteer traditions in addressing critical issues at home and abroad. The two presidents will commemorate the 20^th anniversary of the Points of Light movement, championed by the 41^st president, and advance the United We Serve initiative of President Obama.

Michelle Nunn, CEO of Points of Light Institute and daughter of former Democratic Senator Sam Nunn noted in Huffington Post that “demand, idealism and presidential impact are leading American volunteerism to its…most important stage – the movement of service to a central role in our nation’s priorities.”

The bipartisan nature of America’s vibrant service movement is also reflected in the landmark Kennedy-Hatch Serve America Act signed into law by President Obama earlier this year and pending Global Service Fellowship legislation introduced by Senators Feingold and Voinovich.

In a recent Brookings Global Views policy brief, “International Volunteer Service: A Smart Way to Build Bridges,” Lex Rieffel, Kevin Quigley and I articulate policy options for the new administration to advance President Obama’s call for engaging service on the global level. President Obama’s speech in Cairo on June 4 called for turning “dialogue into interfaith service, so bridges between peoples lead to action – whether it is combating Malaria in Africa, or providing relief for a natural disaster.”

Following the president’s Cairo speech, the administration assembled a laudable Global Engagement Initiative across the administration to implement and track results in scaling up initiatives of service and interfaith action. The potency of coupling American service with foreign assistance was documented in Indonesia and Bangladesh through successive Terror Free Tomorrow polls showing increased favorable ratings for our nation and decreased support for terrorism.

The Building Bridges Coalition has organized an impressive array of over 210 organizations dedicated to expanding American volunteerism internationally, as part of a new “Service World” policy coalition gearing up for the 50^th anniversary of the Peace Corps. This new “international service 2.0” incorporates NGOs and faith-based groups, universities and corporations as new development actors advocating multilateral service and achieving impacts on issues ranging from Malaria to peacebuilding and climate change.

A Foundation Strategy Group report commissioned by Brookings and Pfizer, “Volunteering for Impact” assessed best practices in the increasing array of international corporations engaging volunteers such as IBM’s Corporate Service Corps, GE Volunteers and Pfizer’s Global Health Fellows.

Around the globe, initiatives such as Cross Cultural Solutions and an emerging global service and peacebuilding alliance in hot spots from Kenya to Mindanao are giving substance to the president’s call in Cairo. The collaboration of Presidents Clinton and G.H.W. Bush on humanitarian assistance after the tsunami, and this week’s service dedication with the Obama administration and former President Bush, bode well for the bipartisan extension of our nation’s noble voluntary service traditions in the international context where they are urgently needed.

Event Information

On June 23, Global Economy and Development at Brookings and Washington University’s Center for Social Development hosted a forum to examine how international volunteering and service serve as critical tools for meeting global challenges.

The forum framed international service as an integral component of “smart power” diplomacy and as a cost effective way to build cross-cultural bridges. Ambassador Elizabeth Frawley Bagley, special representative for global partnerships at the U.S. Department of State, delivered a keynote address on how the United States can better promote international service and its impact on American diplomacy, national security and global economies.

The research panel released new data on the impact of international service on volunteers, host communities and host country perceptions of volunteers from the United States. Policymakers and sector leaders discussed options for enhancing international service, and provided recommendations for bringing global service to the forefront of American foreign policy initiatives.

View the keynote speech by Ambassador Bagley »

Video

• Global Development's National Responsibility
• Emphasize Core Competencies in Volunteering
• Shared Global Responses to Shared Global Problems
• Young People Want To Make World Better Place
• Data Are Important to Enhancing Volunteerism

Audio

• International Volunteering and Service
• International Volunteering and Service
• International Volunteering and Service
• International Volunteering and Service

Transcript

• Full Uncorrected Transcript (.pdf)
• Welcoming Remarks, Opening Remarks and Keynote - Transcript (.pdf)
• Panel One - Transcript (.pdf)
• Panel Two - Transcript (.pdf)
• Closing Remarks - Transcript (.pdf)

Event Materials

• 20100623_volunteering
• 20100623_volunteering_intro
• 20100623_volunteering_panel1
• 20100623_volunteering_panel2
• 20100623_volunteering_closing_remarks

David Caprara, a Brookings nonresident fellow and expert on volunteering, says that John F. Kennedy’s call to service a half-century ago led to the founding of dozens of international aid organizations, and leaves a legacy of programs aimed at improving health, nutrition, education, living standards and peaceful cooperation around the globe.

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• International Volunteering

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• @ Brookings Podcast: International Volunteers and the 50th Anniversary of the Peace Corps

Robert Sargent Shriver, Jr. guided the Peace Corps from its inception in 1961 (when it was a nascent vision of service and citizen diplomacy) to establish a renowned track record of success over the past half century, in which more than 200,000 volunteers and trainees have served in 139 countries.

The legacy of Shriver’s leadership with the Peace Corps and later with the Office on Economic Opportunity and Special Olympics has reached and changed millions of lives—of both those empowered and those who served—from impoverished communities across rural and urban America to huts and villages in developing nations throughout the world. Yet one of the greatest gifts he leaves us is the foundation to build on those accomplishments to scale-up service as a direly needed “soft power” alternative to establish international understanding and collaboration in a volatile world. As Sarge put it, so simply but powerfully: “Caring for others is the practice of peace.”

Sarge Shriver’s unquenchable idealism today is being advanced by a new generation of social entrepreneurs such as Dr. Ed O’Neil, founder of OmniMed and chair of the Brookings International Volunteering Project health service policy group. With the help of Peace Corps volunteers and USAID-supported Volunteers for Prosperity, O’Neil has fielded an impressive service initiative in Ugandan villages that has expanded the capacity and reach of local health-service volunteers engaged in malaria prevention and education on basic hygiene. 

Timothy Shriver, who succeeded his parents, Sarge and Eunice, at the helm of the Special Olympics, speaks eloquently on the move of a second generation from politics to building civil society coalitions promoting soft power acts of service and love, one at a time. This impulse is echoed in the Service World policy platform which hundreds of NGOs and faith-based groups, corporations and universities have launched to scale-up the impact of international service initiatives. This ambitious undertaking was first announced by longtime Shriver protégé former Senator Harris Wofford at a Service Nation forum convened on the morning of President Obama’s Cairo speech in which he called for a new wave of global service and interfaith initiatives.

I had the privilege of serving as a national director of the VISTA program inspired by Shriver and  to work alongside Senator Wofford and John Bridgeland, President George W. Bush’s  former White House Freedom Corps director, who have co-chaired the Brookings International Volunteering Project policy team. Along with Tim Shriver, they have ignited the Service World call to action, together with Michelle Nunn of Points of Light Institute, Steve Rosenthal of the Building Bridges Coalition, Kevin Quigley of the National Peace Corps Association and many others.

The Obama administration and Congress would best honor the life and legacy of Sarge Shriver by calling for congressional hearings and fast- tracking agency actions outlined in the Service World platform and naming the global service legislation after him. Coupled with innovative private-sector and federal agency innovations, the legislation would authorize Global Service Fellowships, link volunteer capacity-building to USAID development programs such as  Volunteers for Prosperity, and double the Peace Corps to reach a combined goal of 100,000 global service volunteers annually—a goal first declared by JFK.

Those who promote opportunity and service as vehicles to advance peace and international collaboration will continue to draw inspiration from Sargent Shriver’s indefatigable quest for social justice―from the time he talked then-Senator John F. Kennedy into intervening in the unjust jailing of Martin Luther King, Jr. to his refusal to accept wanton violence and impoverished conditions in any corner of the world.

Information on offering online tributes to the Shriver family and donations in lieu of flowers requested by the family of Sargent Shriver can be found at www.sargentshriver.org .

INTRODUCTION

In December 2011, the United Nations State of the World’s Volunteering Report was released at the U.N. headquarters in New York along with a General Assembly resolution championing the role of volunteer action in peacebuilding and development. The United Nations Volunteers (UNV) Program report states that:

The contribution of volunteerism to development is particularly striking in the context of sustainable livelihoods and value-based notions of wellbeing. Contrary to common perceptions, the income poor are as likely to volunteer as those who are not poor. In doing so, they realize their assets, which include knowledge, skills and social networks, for the benefit of themselves, their families and their communities…Moreover, volunteering can reduce the social exclusion that is often the result of poverty, marginalization and other forms of inequality…There is mounting evidence that volunteer engagement promotes the civic values and social cohesion which mitigate violent conflict at all stages and that it even fosters reconciliation in post-conflict situations...

The “South Africa Conference on Volunteer Action for Development” convened in Johannesburg in October 2011, and the July 2012 “Africa Conference on Volunteer Action for Peace and Development” co-hosted with the Kenya’s Ministry of East African Community, the United Nations and partners in Nairobi give further evidence to the rise of and potential for volunteer service to impact development and conflict. Indeed, in the aftermath of the 2011 Arab Spring, youth volunteer service and empowerment have emerged as a pivotal idea in deliberations aimed at fostering greater regional cohesion and development.

In “Foresight Africa: Top Priorities for the Continent in 2012,” Mwangi S. Kimenyi and Stephen N. Karingi note that: “One of the most important pillars in determining whether the positive prospects for Africa will be realized is success in regional integration… This year is a crucial one for Africa’s regional integration project and actions by governments, regional organizations and the international community will be critical in determining the course of the continent’s development for many years to come.”

The authors note the expected completion of a tripartite regional free trade agreement by 2014 and the expected boost to intra-African trade, resulting in an expanded market of 26 African countries (representing more than half of the region’s economic output and population). At the same time, the declaration from the “South Africa Conference on Volunteer Action for Development” calls on “Governments of Southern African member states and other stakeholders to incorporate volunteering in their deliberations from Rio +20 and to recognize the transformational power as well as economic and social value of volunteering in achieving national development goals and regional priorities, which can be achieved by facilitating the creation of an enabling environment for volunteering to support, protect and empower volunteers.” This speaks directly to the urgent need to factor the social dimension into the regional integration agenda in the different African subregions.

This paper includes examples of the growth of volunteer service as a form of social capital that enhances cohesion and integration across three regions: southern, western, and eastern Africa. It further highlights civil society best practices and policy recommendations for increased volunteering in efforts to ensure positive peace, health, youth skills, assets and employment outcomes.

The importance of volunteering to development has been noted in recent United Nations consultations on the Rio+20 convening on sustainable development and the post-2015 development framework. As the U.N. reviews its Millennium Development Goals (MDG) process, Africa’s regional service initiatives offer vital lessons and strategies to further achieve the MDGs by December 2015, and to chart the way forward on the post-2015 development framework.

But how does volunteerism and civic service play out in sub-Saharan Africa? What are its institutional and non-institutional expressions? What are the benefits or impacts of volunteerism and civic service in society? Our specific purpose here is to provide evidence of the different manifestations and models of service, impact areas and range of issues in three African regions. In responding to these questions, this analysis incorporates data and observations from southern, western and eastern Africa.

In conclusion, we provide further collective insights and recommendations for the roles of the Africa Union and regional economic communities (RECs), youth, the international community, the private sector and civil society aimed at ensuring that volunteerism delivers on its promise and potential for impact on regional integration, youth development and peace.

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