The RAND Blog

This commentary appeared on Health Affairs Blog on December 21, 2012.

The horrific massacre of 27 children and adults in Newtown, Connecticut ranks second only to Virginia Tech among U.S. mass shootings. These tragedies are part of a lengthening list of mass killings in such varied places as a shopping mall, a movie theater, a Sikh Temple, a high school, a congressional constituent meeting, and a military base. But this one was different. Not only were the death toll particularly high and the killings particularly savage; the killer's victims were first-grade students, teachers and school staff.

Millions are deeply touched by this tragedy, but few of us can fathom the shock and grief felt by the survivors, parents, family members and friends of those who died. Our first concern must be to comfort them and support what will likely be a long and difficult recovery. But few people are prepared to stop with that. This event, unlike its predecessors, has sparked a movement to challenge the inevitability of mass shootings, not to mention the thousands of individual gun homicides that occur each year in the United States.

In the coming weeks and months, we will hear numerous calls for better mental health programs and policies as a way to prevent tragedies such as the Newtown, Conn., shooting. As news and details trickle out, we may or may not emerge with a complete picture of what led Adam Lanza to take his anger out on his mother and 26 innocent lives.

The latest reports paint a picture of a mother struggling to care for her troubled adult son. And as many families can attest, the challenges of caring for a young or adult child with severe mental illness or emotional or behavioral disturbance are profound and heartbreaking. In our national conversation on mental health, we should remember the role of families when thinking about mental health treatment and ensure that our policies open up opportunities to support parents, siblings and relatives, and enhance their capacity for care.

This commentary appeared in The Hill on December 20, 2012.

As the president and Speaker Boehner seek agreement to avoid the fiscal cliff, avoiding damaging across-the-board slashes in funding for defense is vital. The administration has already reduced defense expenditures by $500 billion over the next decade, cuts balanced in their application. The sequester would require additional and unbalanced cuts of an equal size. Even if applied selectively, that would severely damage national security.

In practical political terms, some budget reductions beyond those already adopted are certain. However, they must be applied in ways that pose the least risk to national security. We need to shrink force structure carefully, reduce or delay procurement of some weapons systems, streamline management and cut personnel costs.

This commentary appeared on U.S. News & World Report on December 21, 2012.

Egyptians go to the polls Saturday for a second day of voting in a referendum on a draft constitution. Fifty-seven percent of voters in the parts of Egypt where polling was conducted last Saturday approved the draft, and when all is said and done, the yes votes probably will outpace the no votes by a larger margin than that.

Nevertheless, Egypt has missed its "constitutional moment." What could have been a process used to build consensus among disparate political forces and segments of Egyptian society instead became divisive. South Africa's post-Apartheid constitution, developed through a lengthy process of negotiation, public consultation, and consensual decision-making, was called by some the "birth certificate" of a new nation. Egypt's rushed and opaque constitution-making process has produced something more like a driver's license for the Muslim Brotherhood; it has proved that the Brotherhood can steer post-revolution Egyptian politics, though it's not yet clear to what destination.

This commentary appeared on The Journal of the American Medical Association on December 21, 2012.

On December 14, a 20-year-old Connecticut man shot and killed his mother in the home they shared. Then, armed with 3 of his mother's guns, he shot his way into a nearby school, where he killed 6 additional adults and 20 first-grade children. Most of those who died were shot repeatedly at close range. Soon thereafter, the killer shot himself. This ended the carnage but greatly diminished the prospects that anyone will ever know why he chose to commit such horrible acts.

In body count, this incident in Newtown ranks second among US mass shootings. It follows recent mass shootings…

The remainder of this op-ed can be found at jama.jamanetwork.com.

North Korea's latest missile launch briefly appeared to have put a satellite into orbit for the first time—leading to euphoric rejoicing in the country—although the satellite may never actually function. While final analysis is yet to emerge, news reports suggest the satellite was not placed in the intended orbit and is now tumbling out of control.

That is not the story being told in North Korea, of course, but then North Korea lied about the success of some of its previous satellite launches (which must make some inside North Korea wonder about the claim that the North finally succeeded in putting a satellite into orbit this time). All four previous attempts to place a satellite in orbit had not succeeded, including one in April this year. In each case, the missile had failed, twice before separation of the first and second stage, and twice apparently in the staging process.

I've spent much time since Friday imagining the unimaginable—little children murdered in the place that is supposed to be their home-away-from-home, their elementary school. The media fed my curiosity. I could not stay away from checking the news and blogs hourly, despite my family's pleas to stop reading and my own knowledge that it can be too much to read so many details, see so many pictures, grieve from afar.

It's because I want to help. I am a psychologist, and this is why I went into the profession and made trauma my focus. I know from a vast amount of research that many of those touched by Friday's shootings will experience a great deal of distress in the weeks and months ahead. But they will, somehow, miraculously, find a pathway forward to health and productivity. And I am reassured that over the past 15 years or so, we have developed a wide array of practices, procedures, and interventions that are well-tested and helpful for those children that will take longer to recover.

RAND congratulates Art Kellermann, M.D., Paul O'Neill–Alcoa Chair in Policy Analysis, on being named by his peers to serve on the Institute of Medicine's (IOM) Council of Governors. Dr. Kellermann joins six other IOM colleagues on the council, which is responsible for approving IOM studies, overseeing budget and investments, and guiding policy for the highly influential organization. Dr. Kellermann was elected to the Institute of Medicine in 1999, and co-chaired the IOM Committee on the Consequences of Uninsurance, which issued six reports between 2001 and 2004. He also served on the IOM's Committee on the Future of Emergency Care in the U.S. Health System and the Committee on Effectiveness of National Biosurveillance Systems: BioWatch and the Public Health System. He will serve a three-year term on the Governing Council.

This commentary appeared in The International Economy on December 1, 2012.

The Cold War was, in large part, about weapons of mass destruction. Today's hand-wringing over the villainies certain to visit us in cyberspace is primarily about weapons of mass distraction.

Despite nearly twenty years of predictions, the total physical damage from cyberattacks so far has been low compared even to the smallest of real wars. No one has died. Very little machinery has been broken. One exception, Stuxnet, was a concentrated effort by first-rate cyber powers focused on a nuclear enrichment facility managed by a third-rate industrial power (Iran) with scant mastery of the process, a jerry-rigged collection of blackand gray-market parts, and very little help from the outside world. Extrapolating such limited success (80 percent of the centrifuges survived the attack) into a Cold War II is more than a bit of a stretch. What appear to have been revenge attacks against U.S. banks in September deprived bank customers of online access—an annoyance, to be sure—but the perpetrators have not managed to penetrate banking systems or challenge the integrity of the financial system. This kind of war we can survive easily.

The historic Patient Protection and Affordable Care Act (PDF), usually referred to as the ACA, or "Obamacare," focuses primarily on extending coverage to uninsured Americans. But it is also intended to help curb cost growth. One of the key tools for doing that is the "accountable care organization," or ACO—an alternative delivery model intended to lower costs while also improving quality of care.

It's perhaps not obvious how organizations (rather than individuals) become "accountable" for care. For clarification, RAND turned to M. Susan Ridgely, JD, a senior health policy analyst at RAND and an expert on health policy reform and payment models.