Editor’s Note: The following piece is a chapter from the 2012 edition of Eurasian Development Bank’s Eurasian Integration Yearbook.

INTRODUCTION

For centuries Central Asia was in the backwater of global political and economic attention, tales of “Great Games” and “Silk Roads” notwithstanding. However, interest in Central Asia from outside the region has been on the rise in recent years: Central Asia’s energy resources are of great importance to its neighbours in Europe and Asia. In addition, China wants a peaceful backyard, while Russia considers Central Asia part of its historical economic and regional interests and draws heavily on Central Asia migrants. Turkey is attracted by the common Turkic heritage of the region. Iran shares language and cultural ties with the Tajik people. The Central Asia’s Islamic tradition connects it with the Middle East and other Islamic countries. And now NATO countries rely on Central Asia for transit of their nonlethal military supplies in their engagement in Afghanistan.

There is wide agreement that economic prosperity and political stability in Central Asia is critical not only for the 60-plus million inhabitants of the region, but also for Central Asia’s neighbours, since Central Asia serves as a strategically important land bridge between Europe and Asia. Since the five Central Asian countries are landlocked small economies, a critical prerequisite for long-term economic growth and political stability is successful economic integration underpinned by effective regional cooperation.

This paper therefore addresses the central question of what are the prospects for regional economic integration and regional cooperation in Central Asia. It starts by briefly reviewing the role of Central Asia in the context of the overall process of Eurasian continental economic integration. It then considers what are the benefits and obstacles of regional integration and cooperation in Central Asia against the backdrop of lessons of international experience with regional integration and cooperation, and looks at four of the most important recent regional cooperation initiatives. In closing, the paper provides an answer to the question whether regional integration and cooperation in Central Asia are for real or only a mirage.

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In 2015, 193 countries adopted the Sustainable Development Goals (SDGs), a new global agenda that is more ambitious than the preceding Millennium Development Goals and aims to make progress on some of the most pressing issues of our time. Goal 4, "To ensure inclusive and quality education for all, with relevant and effective learning outcomes," challenges the international education community to meet universal access plus learning by 2030. We know that access to primary schooling has scaled up rapidly over previous decades, but what can be learned from places where transformational changes in learning have occurred? What can governments, civil society, and the private sector do to more actively scale up quality learning?

On April 18-19, the Center for Universal Education (CUE) at Brookings launched "Millions Learning: Scaling Up Quality Education in Developing Countries," a comprehensive study that examines where learning has improved around the world and what factors have contributed to that process. This two-day event included two sessions. Monday, April 18 focused on the role of global actors in accelerating progress to meeting the SDGs. The second session on Tuesday, April 19 included a presentation of the Millions Learning report followed by panel discussions on the role of financing and technology in scaling education in developing countries.

 Join the conversation on Twitter #MillionsLearning

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• Getting millions to learn: What will it take to accelerate progress on meeting the Sustainable Development Goals?
• Scaling quality education: The launch of the Millions Learning report
• Do funders help or hinder scaling in education?
• What role can technology play in scaling education?

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• Getting millions to learn: What will it take to accelerate progress on meeting the Sustainable Development Goals?

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• Uncorrected Transcript - Day 1 (.pdf)
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• 20160418_millions_learning_transcript
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Editor's note: This post originally appeared in the New England Journal of Medicine's Perspective online series on April 22, 2015.

Congress has finally euthanized the sustainable growth rate formula (SGR). Enacted in 1997 and intended to hold down growth of Medicare spending on physician services, the formula initially worked more or less as intended. Then it began to call for progressively larger and more unrealistic fee cuts — nearly 30% in some years, 21% in 2015. Aware that such cuts would be devastating, Congress repeatedly postponed them, and most observers understood that such cuts would never be implemented. Still, many physicians fretted that the unthinkable might happen.

Now Congress has scrapped the SGR, replacing it with still-embryonic but promising incentives that could catalyze increased efficiency and greater cost control than the old, flawed formula could ever really have done, in a law that includes many other important provisions. How did such a radical change occur?  And why now?

The “how” was logrolling — the trading of votes by legislators in order to pass legislation of interest to each of them. Logrolling has become a dirty word, a much-reviled political practice. But the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA), negotiated by House leaders John Boehner (R-OH) and Nancy Pelosi (D-CA) and their staffs, is a reminder that old-time political horse trading has much to be said for it.

The answer to “why now?” can be found in the technicalities of budget scoring. Under the SGR, Medicare’s physician fees were tied through a complex formula to a target based on caseloads, practice costs, and the gross domestic product. When current spending on physician services exceeded the targets, the formula called for fee cuts to be applied prospectively. Fee cuts that were not implemented were carried forward and added to any future cuts the formula might generate. Because Congress repeatedly deferred cuts, a backlog developed. By 2012, this backlog combined with assumed rapid future growth in Medicare spending caused the Congressional Budget Office (CBO) to estimate the 10-year cost of repealing the SGR at a stunning $316 billion.

For many years, Congress looked the costs of repealing the SGR squarely in the eye — and blinked. The cost of a 1-year delay, as estimated by the CBO, was a tiny fraction of the cost of repeal. So Congress delayed — which is hardly surprising.

But then, something genuinely surprising did happen. The growth of overall health care spending slowed, causing the CBO to slash its estimates of the long-term cost of repealing the SGR. By 2015, the 10-year price of repeal had fallen to $136 billion. Even this number was a figment of budget accounting, since the chance that the fee cuts would ever have been imposed was minuscule. But the smaller number made possible the all-too-rare bipartisan collaboration that produced the legislation that President Barack Obama has just signed.

The core of the law is repeal of the SGR and abandonment of the 21% cut in Medicare physician fees it called for this year. In its place is a new method of paying physicians under Medicare. Some elements are specified in law; some are to be introduced later. The hard-wired elements include annual physician fee updates of 0.5% per year through 2019 and 0% from 2020 through 2025, along with a “merit-based incentive payment system” (MIPS) that will replace current incentive programs that terminate in 2018. The new program will assess performance in four categories: quality of care, resource use, meaningful use of electronic health records, and clinical practice improvement activities. Bonuses and penalties, ranging from +12% to –4% in 2020, and increasing to +27% to –9% for 2022 and later, will be triggered by performance scores in these four areas. The exact content of the MIPS will be specified in rules that the secretary of health and human services is to develop after consultation with physicians and other health care providers.

Higher fees will be available to professionals who work in “alternative payment organizations” that typically will move away from fee-for-service payment, cover multiple services, show that they can limit the growth of spending, and use performance-based methods of compensation. These and other provisions will ramp up pressure on physicians and other providers to move from traditional individual or small-group fee-for-service practices into risk-based multi-specialty settings that are subject to management and oversight more intense than that to which most practitioners are yet accustomed.

Both parties wanted to bury the SGR. But MACRA contains other provisions, unrelated to the SGR, that appeal to discrete segments of each party. Democrats had been seeking a 4-year extension of CHIP, which serves 8 million children and pregnant women. They were running into stiff head winds from conservatives who wanted to scale back the program. MACRA extends CHIP with no cuts but does so for only 2 years.  It also includes a number of other provisions sought by Democrats: a 2-year extension of the Maternal, Infant, and Early Childhood Home Visiting program, plus permanent extensions of the Qualified Individual program, which pays Part B Medicare premiums for people with incomes just over the federal poverty thresholds, and transitional medical assistance, which preserves Medicaid eligibility for up to 1 year after a beneficiary gets a job.

The law also facilitates access to health benefits. MACRA extends for two years states’ authority to enroll applicants for health benefits on the basis of data on income, household size, and other factors gathered when people enroll in other programs such as the Supplemental Nutrition Assistance Program, the National School Lunch Program, Temporary Assistance to Needy Families (“welfare”), or Head Start. It also provides $7.2 billion over the next two years to support community health centers, extending funding established in the Affordable Care Act.

Elements of each party, concerned about budget deficits, wanted provisions to pay for the increased spending. They got some of what they wanted, but not enough to prevent some conservative Republicans in both the Senate and the House from opposing final passage. Many conservatives have long sought to increase the proportion of Medicare Part B costs that are covered by premiums. Most Medicare beneficiaries pay Part B premiums covering 25% of the program’s actuarial value. Relatively high-income beneficiaries pay premiums that cover 35, 50, 65, or 80% of that value, depending on their income. Starting in 2018, MACRA will raise the 50% and 65% premiums to 65% and 80%, respectively, affecting about 2% of Medicare beneficiaries. No single person with an income (in 2015 dollars) below $133,501 or couple with income below $267,001 would be affected initially. MACRA freezes these thresholds through 2019, after which they are indexed for inflation. Under previous law, the thresholds were to have been greatly increased in 2019, reducing the number of high-income Medicare beneficiaries to whom these higher premiums would have applied. (For reference, half of all Medicare beneficiaries currently have incomes below $26,000 a year.)

A second provision bars Medigap plans from covering the Part B deductible, which is now $147. By exposing more people to deductibles, this provision will cause some reduction in Part B spending. Everyone who buys such plans will see reduced premiums; some will face increased out-of-pocket costs. The financial effects either way will be small.

Inflexible adherence to principle contributes to the political gridlock that has plunged rates of public approval of Congress to subfreezing lows. MACRA is a reminder of the virtues of compromise and quiet negotiation. A small group of congressional leaders and their staffs crafted a law that gives something to most members of both parties. Today’s appalling norm of poisonously polarized politics make this instance of political horse trading seem nothing short of miraculous.

The eurozone has three problems: national debt obligations that cannot be met, medium-term imbalances in trade competitiveness, and long-term structural flaws.

The short-run problem requires more of the monetary easing that Germany has, with appalling shortsightedness, been resisting, and less of the near-term fiscal restraint that Germany has, with equally appalling shortsightedness, been seeking. To insist that Greece meet all of its near-term current debt service obligations makes about as much sense as did French and British insistence that Germany honor its reparations obligations after World War I. The latter could not be and were not honored. The former cannot and will not be honored either.

The medium-term problem is that, given a single currency, labor costs are too high in Greece and too low in Germany and some other northern European countries. Because adjustments in currency values cannot correct these imbalances, differences in growth of wages must do the job—either wage deflation and continued depression in Greece and other peripheral countries, wage inflation in Germany, or both. The former is a recipe for intense and sustained misery. The latter, however politically improbable it may now seem, is the better alternative.

The long-term problem is that the eurozone lacks the fiscal transfer mechanisms necessary to soften the effects of competitiveness imbalances while other forms of adjustment take effect. This lack places extraordinary demands on the willingness of individual nations to undertake internal policies to reduce such imbalances. Until such fiscal transfer mechanisms are created, crises such as the current one are bound to recur.

Present circumstances call for a combination of short-term expansionary policies that have to be led or accepted by the surplus nations, notably Germany, who will also have to recognize and accept that not all Greek debts will be paid or that debt service payments will not be made on time and at originally negotiated interest rates. The price for those concessions will be a current and credible commitment eventually to restore and maintain fiscal balance by the peripheral countries, notably Greece.

Employment among lower-income men has declined by 11 percent since 1980 and has remained flat among lower-income women. Men and women in the top and middle of the income distribution, on the other hand, have been working as much or more since 1980, creating a growing “work gap” in labor market income between haves and have-nots.   

This paper simulates the effect of five labor market interventions (higher high school graduation rate, minimum wage increases, maintaining full employment, seeing all household heads work full time, and virtual marriages between single mothers and unattached men) on the average incomes of the poorest one-third of American households. They find that the most effective way to increase average incomes of the poorest Americans would be for household heads to work full time, whereas the least effective intervention would be increasing education.

In terms of actual impact on incomes, the simulation of all household heads working full time at their expected wage increased average household earnings by 54 percent from a baseline of $12,415 to $19,163. The research also suggests that even if all household heads worked just some—at expected wages or hours—average earnings would still increase by 16 percent.

The least effective simulation was increasing the high school graduation rate to 90 percent and having half of those “newly” graduated go on to receive some form of post-secondary education. The authors note that the low impact of increasing education on mobility is likely because only one in six of bottom-third adults live in a household in which someone gains a high school degree via the intervention.

Because single parents are disproportionately represented among low-income families, Sawhill and coauthors also explored the impact of adding a second earner to single-parent families through a simulation that pairs low-income, single-mother household heads with demographically similar but unrelated men. That simulation increased the average household earnings of the bottom-third only modestly, by $508, or about 4 percent.

Efforts to increase employment among heads of the poorest households must take into consideration why those household heads aren’t working, they note. According to data from the 2015 Census, the most cited reason for women not working is “taking care of home and family” and for men it is being “ill or disabled.”  

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Last week’s Seventh Summit of the Americas in Panama will be remembered for the historic handshakes and broad smiles shared by Presidents Barack Obama and Raúl Castro—the first sit-down meeting of leaders from the two nations since Fidel Castro marched triumphantly into Havana in early 1959. But this memorable encounter was merely the most visible piece of a much broader Cuban strategy at the Panama Summit.

The large Cuban delegation took full advantage of the several forums that comprise the complex Summit process. These periodic inter-American conclaves feature meetings among heads of state and foreign ministers, a CEO Summit for corporate executives, and a Civil Society Forum for representatives of nongovernmental organizations (NGOs). The Cubans seized all three opportunities and fielded strong teams to advance their interests: to engage with the multi-level inter-American system, and to send clear signals back home of where government policy is headed.

Face-to-face diplomacy

In addition to the Obama-Castro encounter, foreign ministers John Kerry and Bruno Rodriguez held a lengthy bilateral. Since Obama and Castro publicly announced their intention to renew relations on December 17 of last year, negotiations have dragged on. Cuba is reluctant to grant American diplomats unrestricted travel throughout the island to engage with Cuban citizens, including political dissidents. This is the norm in international diplomacy, the United States argues, whereas the Cubans remain fearful that U.S. diplomats will provide encouragement and assistance to activists advocating for political pluralism. The Cubans want to be removed from the U.S. list of state sponsors of terrorism, a designation which automatically invokes economic sanctions. The White House is withholding that relief as a bargaining chip in the negotiations.

In his opening plenary remarks, President Castro spoke passionately and at length, impressing the audience with his heartfelt remarks even as he came across as an elder statesman indulging in the memories and glories of his youth. Yet, Castro was also sending signals to the stalwarts in the Communist Party back home that he had not forgotten their sacrifices and was not abandoning their values. His engagement with the United States would not be allowed to endanger their tight control of Cuban society. Still, most significantly, Castro kept the door open to engagement with the United States by dramatically addressing President Obama, tossing him compliments: “President Obama is an honest man…I have read his two memoirs and I believe he is a man who has remained faithful to his humble origins.”

By lauding Obama, holding a private bilateral, and appearing with a broad smile at a press opportunity, Castro reaffirmed his commitment to improving relations with the United States. He also may have been nudging his negotiators to wrap up the talks to allow the mutual re-opening of embassies. The Cubans are aware that not all of Washington favors improved relations, and that they must consolidate the process of diplomatic normalization while Obama commands the White House.

The CEO and Civil Society Forums

Presumably, the main Cuban motivation for engaging the United States is economic: to attract more tourists, financial remittances, and eventually productive investments from the United States and the rest of the world, and to extract a relaxation of sanctions, particularly those impeding international financial transactions. Cuban Minister of Trade and Investment Rodrigo Malmierca led a commercial delegation that included top executives from state-owned enterprises, as well as leadership from the new Mariel Development Zone. At the CEO Summit, Malmierca was granted one of the few time slots for a keynote address. But rather than take advantage of this unique opportunity, the Cuban minister rushed through an uninspired text, offering nothing that could not be found in previous government press releases and official documents. More than two years after the passage of a much-heralded foreign investment law and over a year after the official opening of the Mariel Development Zone, very few new investments have earned official authorization.  

While potentially interested in Cuban markets, executives I spoke with remain cautious, skeptical that the government has yet created a sufficiently business-friendly environment to warrant the risk. They speculate as to why so few new foreign ventures are underway: is it opposition from well-placed hard-liners, bureaucratic inertia, or lack of financing or other necessary business inputs? In private conversations, Malmierca hinted at a political obstacle: many Cubans identify the revolution with nationalizations of private property, so it will be difficult to explain to them why foreign investment is now so welcome.

The Cubans also fielded a significant presence at the Civil Society Forum. The dominant group represented government-affiliated “non-governmental” organizations (GONGOS) such as the official trade union or Confederation of Cuban Women, while opposition NGOs marshalled about a dozen persons. At a pre-Summit speech in Caracas, Castro had ominously labelled these opposition NGOs “mercenaries” in the pay of foreign intelligence services. Following that lead, the government-affiliated group staged aggressive, noisy demonstrations denouncing the opposition representatives and accusing them of harboring infamous terrorists. The GONGOS threatened to boycott the Forum (although some did eventually participate), and disrupted the Forum’s working group on democratic governance. Here again, the message being telegraphed back home was clear: the Cuban government does not consider these opposition voices to be legitimate actors and loyal Cuban citizens should not associate with them.

Discernable signals

Altogether, at the three forums the Cubans demonstrated their strong interest in participating actively in hemispheric affairs and institutions. The Cubans are capable of fielding smart, disciplined delegations with well-scripted strategies and messages. Once again, the high-quality Cuban diplomacy demonstrated that it has few peers in Latin America and the Caribbean.

The messages transmitted at the Panama Summit were subtle but decodable. In the diplomatic sphere, Castro wants to move forward, to take advantage of Obama’s tenure to relax U.S.-Cuban tensions and gain some economic advantages. In the business sphere, Malmierca reaffirmed Castro’s oft-repeated admonitions that economic change on the island will be very gradual and socialist planning will not be discarded under his watch. In the political sphere, the Cuban Communist Party intends to maintain its absolute hegemony—political pluralism outside the Party is definitely not yet on the policy agenda.

Read more about the Summit with Richard Feinberg's post on how the United States came out of the Panama Summit of the Americas.

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