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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Last week, world leaders agreed on an ambitious set of Sustainable Development Goals (SDGs) for 2030. Fully costed, the price tag for achieving these goals over the next 15 years will run into the trillions of dollar, however. The implication is that everyone in the world will have to contribute in one way or another—private businesses as well public sector agencies.

Volunteers seem to be the least recognized group of contributors, despite being the least-expensive component. They often play a crucial role in “the last mile” of program implementation. Volunteer service in support of the SDGs also enriches the lives of volunteers and helps to building the sense of global citizenship that is essential for global peace and well-being.

For the individuals involved, the core benefit of volunteer action comes from working outside of your culture. Making sandwiches for your children is not volunteer action. Making sandwiches at a shelter for the homeless is.

This concept of volunteer action, or service, was probably absent in primitive tribal communities and in early civilizations—such as Egypt—where slavery was embedded in the culture. It was certainly present, however, in the great religions that subsequently emerged and evolved, including Buddhism, Judaism, Christianity, and Islam. It is implicit in the messages that Pope Francis brought to the United States and the United Nations earlier this month.

Volunteer action took a great leap forward when President John F. Kennedy established the Peace Corps in 1961 for international service and President Lyndon B. Johnson created VISTA in 1965 for domestic service. The evolution since then has been interesting.

The Peace Corps grew quickly to almost 16,000 volunteers in the field in the mid-1960s, dropped to as low as 4,000 in the 1970s, and grew back slowly to around 8,000 in the early 1990s. It has been stuck at this level since then, despite campaign promises by Presidents Clinton, Bush, and Obama to double the number of serving volunteers.

Meanwhile, a bubbling universe of international volunteer programs emerged in the United States. University-sponsored, corporation-sponsored, NGO-sponsored, and for-profit programs are sending more than 50,000 Americans to foreign countries for short-term and long-term service every year. Inspired by the Peace Corps, other advanced countries also created their own international volunteer programs.

The evolution of government-supported volunteer programs domestically was quite different. In 1993, President Clinton established the Corporation for National and Community Service to manage a new AmeriCorps program along with VISTA and several other small pre-existing programs. AmeriCorps has grown rapidly to the point of having 75,000 volunteers today engaged in full-time, one-year service commitments. Officials from other countries—both advanced and developing—have also been coming here for 20 years to see how AmeriCorps works, before then starting similar domestic service programs in their countries.

Two forces are driving the volunteer movement globally. The first is budget constraints everywhere. In our modern societies, everybody wants to enjoy a good life, but we haven’t figured out how to get enough tax revenue to pay the teachers, health workers, engineers, and community organizers needed to achieve this happy outcome. We have, however, figured out how to mobilize volunteers to provide these services to the neediest.

The second force is an abstract concept combining civic duty and helping the less fortunate. As modern societies have become wealthier, this concept has become more powerful.

Two manifestations of these forces are especially relevant now.

The first is the role of volunteers that has been incorporated in the U.N. Sustainable Development Goals. Implementation is receiving more attention in the SDG process than it received in the preceding Millennium Development Goal process. The U.N has recognized that mobilizing volunteers effectively will be necessary to achieve every one of the SDGs. No government has a budget big enough to pay a living wage for all the hours of work that will be required to meet its own SDGs.

The other manifestation is a new debate in the United States about “national service.” Since the military draft was terminated in 1973, concern has slowly grown about having a military force that does not reflect the broad population. It is possible that the sense of national unity felt so strongly after World War II was related to the experience of so many men and women performing national service outside their culture. That kind of service was a social and civic glue that seems in short supply now.

The Aspen Institute’s “Franklin Project” aims to create a one-year national service commitment—either civilian or military—that becomes a valued part of growing up in America. It can help cure the divisiveness by taking us outside our culture and helping us appreciate others. It can be a better kind of glue.

Volunteer action across borders can also be a better kind of glue for the whole world. 

SDGs) for 2030. Fully costed, the price tag for achieving these goals over the next 15 years will run into the trillions of dollar, however. The implication is that everyone in the world will have to contribute in one way or another—private businesses as well public sector agencies.

Volunteers seem to be the least recognized group of contributors, despite being the least-expensive component. They often play a crucial role in “the last mile” of program implementation. Volunteer service in support of the SDGs also enriches the lives of volunteers and helps to building the sense of global citizenship that is essential for global peace and well-being.

For the individuals involved, the core benefit of volunteer action comes from working outside of your culture. Making sandwiches for your children is not volunteer action. Making sandwiches at a shelter for the homeless is.

This concept of volunteer action, or service, was probably absent in primitive tribal communities and in early civilizations—such as Egypt—where slavery was embedded in the culture. It was certainly present, however, in the great religions that subsequently emerged and evolved, including Buddhism, Judaism, Christianity, and Islam. It is implicit in the messages that Pope Francis brought to the United States and the United Nations earlier this month.

Volunteer action took a great leap forward when President John F. Kennedy established the Peace Corps in 1961 for international service and President Lyndon B. Johnson created VISTA in 1965 for domestic service. The evolution since then has been interesting.

The Peace Corps grew quickly to almost 16,000 volunteers in the field in the mid-1960s, dropped to as low as 4,000 in the 1970s, and grew back slowly to around 8,000 in the early 1990s. It has been stuck at this level since then, despite campaign promises by Presidents Clinton, Bush, and Obama to double the number of serving volunteers.

Meanwhile, a bubbling universe of international volunteer programs emerged in the United States. University-sponsored, corporation-sponsored, NGO-sponsored, and for-profit programs are sending more than 50,000 Americans to foreign countries for short-term and long-term service every year. Inspired by the Peace Corps, other advanced countries also created their own international volunteer programs.

The evolution of government-supported volunteer programs domestically was quite different. In 1993, President Clinton established the Corporation for National and Community Service to manage a new AmeriCorps program along with VISTA and several other small pre-existing programs. AmeriCorps has grown rapidly to the point of having 75,000 volunteers today engaged in full-time, one-year service commitments. Officials from other countries—both advanced and developing—have also been coming here for 20 years to see how AmeriCorps works, before then starting similar domestic service programs in their countries.

Two forces are driving the volunteer movement globally. The first is budget constraints everywhere. In our modern societies, everybody wants to enjoy a good life, but we haven’t figured out how to get enough tax revenue to pay the teachers, health workers, engineers, and community organizers needed to achieve this happy outcome. We have, however, figured out how to mobilize volunteers to provide these services to the neediest.

The second force is an abstract concept combining civic duty and helping the less fortunate. As modern societies have become wealthier, this concept has become more powerful.

Two manifestations of these forces are especially relevant now.

The first is the role of volunteers that has been incorporated in the U.N. Sustainable Development Goals. Implementation is receiving more attention in the SDG process than it received in the preceding Millennium Development Goal process. The U.N has recognized that mobilizing volunteers effectively will be necessary to achieve every one of the SDGs. No government has a budget big enough to pay a living wage for all the hours of work that will be required to meet its own SDGs.

The other manifestation is a new debate in the United States about “national service.” Since the military draft was terminated in 1973, concern has slowly grown about having a military force that does not reflect the broad population. It is possible that the sense of national unity felt so strongly after World War II was related to the experience of so many men and women performing national service outside their culture. That kind of service was a social and civic glue that seems in short supply now.

The Aspen Institute’s “Franklin Project” aims to create a one-year national service commitment—either civilian or military—that becomes a valued part of growing up in America. It can help cure the divisiveness by taking us outside our culture and helping us appreciate others. It can be a better kind of glue.

Volunteer action across borders can also be a better kind of glue for the whole world. 

Dear Members of the Senate,

As you know, the Senate has debated the merits of the filibuster and related procedural rules for over two centuries. Recently, several senators who are advocating changes to Senate Rule XXII have renewed this discussion. We write this letter today to clarify some of the common historical and constitutional misperceptions about the filibuster and Rule XXII that all too often surface during debates about Senate rules.

First, many argue that senators have a constitutional right to extended debate. However, there is no explicit constitutional right to filibuster.^[1] In fact, there is ample evidence that the framers preferred majority rather than supermajority voting rules. The framers knew full well the difficulties posed by supermajority rules, given their experiences in the Confederation Congress under the Articles of Confederation (which required a supermajority vote to pass measures on the most important matters). A common result was stalemate; legislators frequently found themselves unable to muster support from a supermajority of the states for essential matters of governing. In the Constitution, the framers specified that supermajority votes would be necessary in seven, extraordinary situations -which they specifically listed (including overriding a presidential veto, expelling a member of the Senate, and ratifying a treaty). These, of course, are all voting requirements for passing measures, rather than rules for bringing debate to a close.

Second, although historical lore says that the filibuster was part of the original design of the Senate, there is no empirical basis for that view. There is no question that the framers intended the Senate to be a deliberative body. But they sought to achieve that goal through structural features of the chamber intended to facilitate deliberation -such as the Senate's smaller size, longer and staggered terms, and older members. There is no historical evidence that the framers anticipated that the Senate would adopt rules allowing for a filibuster. In fact, the first House and the first Senate had nearly identical rule books, both of which included a motion to move the previous question. The House converted that rule into a simple majority cloture rule early in its history. The Senate did not.

What happened to the Senate's previous question motion? In 1805, as presiding officer of the Senate, Vice President Aaron Burr recommended a pruning of the Senate's rules. He singled out the previous question motion as unnecessary (keeping in mind that the rule had not yet routinely been used in either chamber as a simple majority cloture motion). When senators met in 1806 to re-codify the rules, they deleted the previous question motion from the Senate rulebook. Senators did so not because they sought to create the opportunity to filibuster; they abandoned the motion as a matter of procedural housekeeping. Deletion of the motion took away one of the possible avenues for cutting off debate by majority vote, but did not constitute a deliberate choice to allow obstruction. The first documented filibusters did not occur until the 1830s, and for the next century they were rare (but often effective) occurrences in a chamber in which majorities generally reigned.

Finally, the adoption of Rule XXII in 1917 did not reflect a broad-based Senate preference for a supermajority cloture rule. At that time, a substantial portion of the majority party favored a simple majority rule. But many minority party members preferred a supermajority cloture rule, while others preferred no cloture rule at all. A bargain was struck: Opponents of reform promised not to block the rule change and proponents of reform promised not to push for a simple majority cloture rule. The two-thirds threshold, in other words, was the product of bargaining and compromise with the minority. As has been typical of the Senate's past episodes of procedural change, pragmatic politics largely shaped reform of the Senate's rules.

We hope this historical perspective on the origins of the filibuster and Rule XXII will be helpful to you as matters of reform are raised and debated. Please do not hesitate to contact us if we can provide additional clarification.

Very truly yours,

Sarah Binder
Senior Fellow, Governance Studies, The Brookings Institution
Professor of Political Science, George Washington University

Gregory Koger
Associate Professor of Political Science, University of Miami

Thomas E. Mann
W. Averell Harriman Chair & Senior Fellow, Governance Studies, The Brookings Institution

Norman Ornstein
Resident Scholar, American Enterprise Institute for Public Policy Research

Eric Schickler
Jeffrey & Ashley McDermott Endowed Chair & Professor of Political Science, University of California, Berkeley

Barbara Sinclair
Marvin Hoffenberg Professor of American Politics Emerita, University of California, Los Angeles

Steven S. Smith
Kate M. Gregg Distinguished Professor of Social Sciences & Professor of Political Science, Washington University

Gregory J. Wawro
Deputy Chair & Associate Professor of Political Science, Columbia University

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Once upon a time, long ago, the development industry was fixated on measuring aid from richer to poorer countries. They called it ODA, standing for Official Development Assistance. For decades this aid has been codified, reported, and tracked, mostly by the Development Assistance Committee of the Organisation for Economic Co-operation and Development (DAC/OECD), a club of advanced economies. In advance of the Spring Meetings of the IMF and World Bank, the DAC announced that ODA has risen by 6.9% over 2014 levels to 132 billion dollars, a record amount. Importantly, ODA increased even after stripping out funds spent on refugees.

The United Nations has established targets for ODA—like the famous 0.7 percent of national income—which have taken on legendary status as benchmarks of national generosity. Only six out of 28 DAC countries met this target last year: Denmark, Luxembourg, The Netherlands, Norway, Sweden and the United Kingdom.

Some institutions and lobby groups remain fixated on ODA, but many development actors now reject it as flawed. A major theme of the Spring Meetings is how to move beyond ODA and expand other forms of financing for development. ODA is, among other things, symptomatic of a charity perspective, rather than investment; inappropriate for South-South cooperation; and unable to capture the big new landscape of public-private links. What’s more, it is riddled with self-serving quirks like scoring numerous flows—the cost of university places in donor countries, and administrative costs of aid agencies—that never reach developing countries.

Perhaps the most telling weakness of ODA is that emerging powers like China and India see little merit (and arguably, some residual stigma) in this concept and, therefore, will not report on that basis to a club to which they do not belong. As their share of the world economy and their interactions with other “developing” countries continue to grow, this means ODA will inevitably start to represent an ever smaller share of official financing for development.

TOSSD stands for Total Official Support for Sustainable Development. The idea, still being fleshed out, is to have a universally accepted measure of the full array of public financial support for sustainable development. TOSSD should differ from ODA in at least three ways:

• First, it should take a developing country perspective rather than a donor country perspective. So it should cover the value of all funding for development that is officially supported, from pure grants to near-market loans and equity investments, as well as guarantees and insurance.
• Second, it should measure cross-border flows from all countries, not just the rich members of the OECD’s Development Assistance Committee.
• Third, it should include contributions to global public goods needed to support development, like U.N. peacekeeping and pandemic surveillance.

There are many complications behind any international attempt to define and track such a huge range of activities. Some are technical, but can probably be resolved with enough goodwill and professionalism. So, for example, we can debate how to establish whether and how official support to private investors changes their behaviour, delivering “additional” development results compared to a situation without that support. In the end, sensible solutions and workarounds will be found.

More difficult are a couple of politically sensitive challenges, which at the same time underlie the value of reaching consensus on a new measure. How far, for example, should the new measure recognise indirect spending on global public goods? Take for example public research on an AIDS vaccine that could lead to prevention of millions of deaths in developing countries. Right now, this would not count as ODA because the promotion of the economic development and welfare of developing countries is not its main objective.

We tend to think that consideration of globe-spanning benefits like these, which do not fit the simple mould of money crossing borders, is an essential feature of a new measure of development finance. However, it will need to be bounded sensibly, not least because of underlying suspicions that the countries that are today most likely to deploy such tools, and claim them as a large part of their distinctive contribution, are among the “old rich”—though that could change quickly. We suggest that spending on a defined list of global public goods should be included, perhaps those that support Agenda 2030, such as U.N. peacekeeping or a global research consortium like GAVI, the Vaccine Alliance.

A second potentially divisive issue, already alluded to, is how to value non-monetary flows, like technical assistance, and in a fair way across countries. We think it would be a powerful positive signal for international cooperation if even modest contributions by low- and middle-income countries are recognised, celebrated, and valued according to the contribution being made, not the cost of providing the assistance. The assistance provided by professionals from developing countries (think Cuban doctors) should be measured at the same prices as assistance provided by professionals from rich countries. Some form of purchasing power parity equivalence would need to be defined and used.

This is a hugely contentious question. Neither of the most obvious answers, the well-organised but globally unloved OECD and the legitimate but under-resourced U.N. secretariat, are likely to be acceptable without some changes. A preferred candidate has to have a sufficiently broad group of countries prepared to self-report on even a loose set of definitions in order to get momentum. At a minimum all the major economies of the world, for example members of the G-20, should be willing to participate. It should also have the technical capacity to help countries provide information in a consistent way.

The International Monetary Fund or World Bank could be candidates—most countries already report to them on a range of data, including financial flows. The Global Partnership for Effective Development Cooperation, with its membership of many development actors and technical support, could be another. Or a new group could be created in much the same way as the International Aid Transparency Initiative. This could even be a revamped Development Assistance Committee that operates with broader support in much the same way as the OECD’s tax work has many non-OECD members participating. What is important is that the guiding principle be to measure official cross-border financial resources that support the new universally-agreed Sustainable Development Goals, and to start now and learn by doing.  Such initiatives are too easily killed by subjecting them to endless external criticism that a perfect solution has not been found.

TOSSD may be one of the least attractive acronyms on offer today. Without disrespect to its OECD authors, it will anyway have to change to something that works for all the major stakeholders, and is not visibly invented in Paris and that also encourages players who are not strictly speaking “official,” like foundations, to sign up. We tend to favor a plainer, simpler wrapper like International Development Contributions (IDC), or Defined Development Contributions (DDC). 

Editors' Note: America has fallen behind its economic competitors—namely Russia and China—in Arctic resource and infrastructure investment. Charles Ebinger argues that the United States must better define its resource development policies and priorities in order to ensure U.S. leadership in the Arctic. This piece was originally published on Forbes. 

The recent decision by the United States to allow energy exploration drilling to re-commence in the Alaskan Arctic’s Chukchi Sea this summer is a welcome development. Here’s why: Federal waters in offshore Alaska are estimated to hold roughly 27 billion barrels of oil and 132 trillion cubic feet of natural gas, the vast majority of which is located in the Arctic. Experts believe that the Chukchi in particular, which holds more resources than any other undeveloped U.S. energy basin, may represent one of the world’s largest sources of untapped oil and gas.

Until now America has regrettably been on the sidelines of Arctic resource and infrastructure investment while our economic competitors—Russia and China included—have moved forward. This policy vacuum was highlighted in a recent National Petroleum Council (NPC) report to the U.S. Secretary of Energy in which I participated and which warned that if we effect no policy changes on an urgent basis we will not stay ahead of or even keep pace with our foreign rivals, remain globally competitive, or provide global leadership and influence in this critical region.

America is more energy self-sufficient than it has ever been

The report comes at a time when the U.S. has cut imports, drastically transforming our nation into the biggest producer of oil and natural gas by tapping huge reserves in shale rock formations across the country. As such, America is more energy self-sufficient than it has ever been. Even so, as evidenced by strong public support for Arctic offshore development in states ranging from Alaska to Iowa, South Carolina and New Hampshire, the American people recognize that we cannot rely solely on shale oil and gas to meet our energy needs.

To that point, as the NPC noted, if we fail to develop the enormous trove of reserves in Arctic waters off Alaska, the U.S. risks a renewed reliance on overseas energy in the future and will have missed a prime opportunity to keep domestic production high and imports and consumer costs low.

As President Obama rightly stated shortly after the Chukchi drilling plan was conditionally approved in May, “When it can be done safely and appropriately, U.S. production of oil and natural gas is important. I would rather us—with all the safeguards and standards that we have—be producing our oil and gas, rather than importing it, which is bad for our people, but is also potentially purchased from places that have much lower environmental standards than we do.

We have to take actions that allow exploration to commence now 

Indeed, given the long lead time necessary to develop resources in this region, the NPC study stressed that it is vital for the U.S. to take actions now that allow exploration in Alaskan Arctic waters to commence. In that regard, the recent approval for Arctic offshore drilling to occur this summer was a win for both Alaska, which is dependent on the petroleum industry to fund approximately 90 percent of its coffers, and the country at large, which leans on Alaskan energy to meet our daily needs, especially on the West Coast.

To ensure the long-term feasibility of offshore development in the region, Interior Department regulations for the U.S. Arctic in part must facilitate the use of proven technologies and also encourage innovation by providing the flexibility to incorporate future technologies as advances occur and their capacities are demonstrated. In addition, and all the more significant given our accession to chairmanship of the Arctic Council in May, U.S. policies governing natural resource development in the Arctic must be defined and streamlined.

Questions Washington has to answer if the U.S. wants to ensure its leadership in the Arctic

For example, what is the country’s official position on the development of oil, gas, mineral and fishery resources in the Arctic? Does it align with Alaska’s policies? How will resource development affect standards of living for those residing in the region?

In addition to resource development policies, other important questions must be addressed to ensure U.S. leadership in the Arctic. With Prudhoe Bay production in serious decline and the Trans-Alaska Pipeline System running at historically low throughput levels, how will the U.S. ensure access to new sources like Alaska’s Arctic offshore that can help all Americans? With just one heavy icebreaker in operation, and the cost of another tallying at least $700 million, what actions are we prepared to take to build a fleet capable of meeting the demands in an increasingly active region?

These are just a few of the questions and concerns that Washington, D.C. will have to answer soon if the U.S. stands a chance of catching up to or surpassing other nations that have so far leapt ahead to the front of the Arctic line. Will President Obama rise to the occasion and make the right decisions?

Cities across America are undergoing massive demographic change, and Philadelphia is no exception. Understanding this change, and effectively managing it, will be key to our national progress and prosperity in this decade and beyond.

A new report from the Brookings Institution, "The State of Metropolitan America," describes a nation that has grown larger, more diverse, more suburban, and more educated in the first decade of this century. These characteristics offer the potential for a tremendous advantage among industrialized nations as the global economy becomes more integrated and more competitive.

The Philadelphia region, for instance, is now home to 92 colleges and universities - more than the renowned concentration of higher education institutions in the Boston area. In our research on the demographic transformation of the nation, we refer to Philadelphia as a "skilled anchor" - one of 19 metro areas, including Baltimore, Rochester, N.Y., and Boston, that have made a transition from manufacturing and shipping to service-based economies. Medical and educational institutions have often driven this transformation, along with specialized manufacturing.

Skilled anchors face challenges, however, due to other trends. While 32 percent of Philadelphia area residents over the age of 25 hold bachelor's degrees, only 21 percent of residents of the city itself have been educated beyond high school.

That is cause for concern, especially as baby boomers begin to retire - most notably in the suburbs, where more than 40 percent of the residents are boomers and seniors. The young people who will take their place in the workforce are not completing college education at the same rate as their predecessors. This is problematic considering that median household income declined during the 2000s, and higher education is closely correlated with higher wages.

Meeting the region's future workforce challenges - that is, connecting residents to high-quality jobs in the education, medicine, life-sciences, and pharmaceutical sectors - will require education policies that prepare all children for successful postsecondary education, so they can build on the economic momentum of the retiring baby boomers.

As part of the national Achieving the Dream Initiative, several foundations are working together to help community colleges in Michigan, Ohio, and Indiana improve completion rates for minority and low-income students who are most at risk of dropping out and not getting the skills and credentials they need to succeed in the workforce.

Other demographic trends represent challenges as well as opportunities. The Philadelphia region's foreign-born population grew by 30 percent in the 2000s, albeit from a relatively small base. Efforts to incorporate immigrants into the mainstream of economic and civic life - such as Philadelphia's language-access policy, its one-stop education office, and the region's emerging Metropolitan Caucus - are all praiseworthy. But more is required.

At the same time, while solutions must be built from the ground up, the Philadelphia region can't go it alone. The federal government can't wait for megacities such as Philadelphia to work out the massive transformation under way by themselves. There are macro-level federal responses to these trends that could and should emanate from Washington.

Among them are comprehensive immigration reform that includes explicit means for improving the integration of new Americans into our society and economy; a revamping of transportation and housing policy that reduces energy-inefficient sprawl, accommodates seniors, and provides access to employment centers; programs to increase postsecondary education for our emerging workforce; and a redoubling of efforts to make work pay for working families, such as the Earned Income Tax Credit.

Over the past decade, between two recessions, Philadelphia has made much progress. Today, the region must capitalize on its hard-earned gains and address emerging challenges with similar conviction.

In the developing world, more than 200 million children under the age of five years are at risk of not reaching their full development potential because they suffer from the negative consequences of poverty, nutritional deficiencies and inadequate learning opportunities. Overall, 165 million children (one in four) are stunted, and 90 percent of these children live in Africa and Asia. And though some progress has been made globally, child malnutrition remains a serious public health problem with enormous human and economic costs. Worldwide, only about 50 percent of children are enrolled in preprimary education, and in low-income countries a mere 17 percent. And though more and more children are going to school, millions have little to show for it. By some accounts, 250 million children of primary school age cannot read even part of a sentence. Some of these children have never been to school (58 million); but more often, they perform poorly despite having spent several years in school, which reflects not only the poor quality of many schools but also the multiple disadvantages that characterize their early life.

Ensuring that all children—regardless of their place of birth and parental income or education level—have access to opportunities that will allow them to reach their full potential requires investing early in their development. To develop their cognitive, linguistic, socioemotional and physical skills and abilities, children need good nutrition and health, opportunities for play, nurture and learning with caregivers, early stimulation and protection from violence and neglect.

The Case for Early Interventions 

The arguments for investing in children early are simple and convincing. Early investment makes sense scientifically. The brain is almost fully developed by age three, providing a prime opportunity to achieve high gains. We know that the rapid rate of development of the brain’s neural pathways is responsible for an individual’s cognitive, social and emotional development, and there is solid evidence that nutrition and stimulation during the first 1,000 days of life are linked to brain development. 

Early investment makes sense in terms of equity. The playing field has the highest chances of being leveled early on, and we know that programs have a higher impact for young children from poorer families. In the United States, for example, increasing preschool enrollment to 100 percent for low-income children would reduce disparities in school readiness by 24 percent between black and white children and by 35 percent between Hispanic and white children. We also know that equalizing initial endowments through early childhood development (ECD) programs is far more cost-effective than compensating for differences in outcomes later in life. 

Early investment makes sense economically. Investing early prevents higher costs down the road, and interventions yield a high return on investment. There is evidence of the benefits for the individual and for society more broadly. For instance, at the level of the individual, in Jamaica children participating in an early childhood stimulation program were found to have 25 percent higher earnings 20 years later compared with children who did not participate. At the economy-wide level, eliminating malnutrition is estimated to increase gross domestic product by 1 to 2 percentage points annually, while countries with school systems that have a 10-percentage-point advantage in the proportion of students

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INTRODUCTION

U.S. public diplomacy with Cuba — or the United States engaging with Cuban public opinion — is an intriguing subject. The principal reason for this is because it has never been tried. There was no attempt before the 1959 Revolution because the United States had no need to convince the Cuban government and people of why the United States mattered to them. In almost every aspect of life it was impossible to conceive of Cuba without the United States. Fidel Castro’s Revolution changed that. And since the Revolution, the Castro regime has carefully molded the United States as the arch enemy of the Cuban people. Successive U.S. administrations have made little effort to banish that impression while U.S. public diplomacy has been largely aimed at the Cuban-American exile community.

The public diplomacy challenge for the United States with Cuba is exciting but also formidable. The Cuban Government has had many years experience of controlling access to information and shackling freedom of expression. The public diplomacy messages that the United States will send will be distorted and blocked. Nevertheless there are growing signs that Cubans on the island are accessing new technologies so information does get through, particularly to residents of the major cities. Expansion of people-to-people exchanges and a lifting of the travel ban on ordinary Americans would greatly assist any public diplomacy campaign. But public diplomacy can start without this and the Cuban government’s capacity to block messages is no argument for not transmitting them.

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At the very heart of the American idea is the notion that, unlike in other places, we can start from nothing and through hard work have everything. That nothing we can imagine is beyond our reach. That we will pull up stakes, go anywhere, do anything to make our dreams come true. But what if that's just a myth? What if the truth is something very different? What if we are…stuck?

I. What does it mean to be an American?

Full disclosure: I'm British. Partial defense: I was born on the Fourth of July. I also have made my home here, because I want my teenage sons to feel more American. What does that mean? I don't just mean waving flags and watching football and drinking bad beer. (Okay, yes, the beer is excellent now; otherwise, it would have been a harder migration.) I'm talking about the essence of Americanism. It is a question on which much ink—and blood—has been spent. But I think it can be answered very simply: To be American is to be free to make something of yourself. An everyday phrase that's used to admire another ("She's really made something of herself") or as a proud boast ("I'm a self-made man!"), it also expresses a theological truth. The most important American-manufactured products are Americans themselves. The spirit of self-creation offers a strong and inspiring contrast with English identity, which is based on social class. In my old country, people are supposed to know their place. British people, still constitutionally subjects of Her Majesty Queen Elizabeth, can say things like "Oh, no, that's not for people like me." Infuriating.

Americans do not know their place in society; they make their place. American social structures and hierarchies are open, fluid, and dynamic. Mobility, not nobility. Or at least that's the theory. Here's President Obama, in his second inaugural address: "We are true to our creed when a little girl born into the bleakest poverty knows that she has the same chance to succeed as anybody else because she is an American; she is free, and she is equal, not just in the eyes of God but also in our own."

Politicians of the left in Europe would lament the existence of bleak poverty. Obama instead attacks the idea that a child born to poor parents will inherit their status. "The same chance to succeed as anybody else because she is an American…."

Americanism is a unique and powerful cocktail, blending radical egalitarianism (born equal) with fierce individualism (it's up to you): equal parts Thomas Paine and Horatio Alger. Egalitarian individualism is in America's DNA. In his original draft of the Declaration of Independence, Thomas Jefferson wrote that "men are created equal and independent," a sentiment that remained even though the last two words were ultimately cut. It was a declaration not only of national independence but also of a nation of independents.

The problem lately is not the American Dream in the abstract. It is the growing failure to realize it. Two necessary ingredients of Americanism—meritocracy and momentum—are now sorely lacking.

America is stuck.

Almost everywhere you look—at class structures, Congress, the economy, race gaps, residential mobility, even the roads—progress is slowing. Gridlock has already become a useful term for political inactivity in Washington, D. C. But it goes much deeper than that. American society itself has become stuck, with weak circulation and mobility across class lines. The economy has lost its postwar dynamism. Racial gaps, illuminated by the burning of churches and urban unrest, stubbornly persist.

In a nation where progress was once unquestioned, stasis threatens. Many Americans I talk to sense that things just aren't moving the way they once were. They are right. Right now this prevailing feeling of stuckness, of limited possibilities and uncertain futures, is fueling a growing contempt for institutions, from the banks and Congress to the media and big business, and a wave of antipolitics on both left and right. It is an impotent anger that has yet to take coherent shape. But even if the American people don't know what to do about it, they know that something is profoundly wrong.

II. How stuck are we?

Let's start with the most important symptom: a lack of social mobility. For all the boasts of meritocracy—only in America!—Americans born at the bottom of the ladder are in fact now less likely to rise to the top than those situated similarly in most other nations, and only half as likely as their Canadian counterparts. The proportion of children born on the bottom rung of the ladder who rise to the top as adults in the U.S. is 7.5 percent—lower than in the U.K. (9 percent), Denmark (11.7), and Canada (13.5). Horatio Alger has a funny Canadian accent now.

It is not just poverty that is inherited. Affluent Americans are solidifying their own status and passing it on to their children more than the affluent in other nations and more than they did in the past. Boys born in 1948 to a high-earning father (in the top quarter of wage distribution) had a 33 percent chance of becoming a top earner themselves; for those born in 1980, the chance of staying at the top rose sharply to 44 percent, according to calculations by Manhattan Institute economist Scott Winship. The sons of fathers with really high earnings—in the top 5 percent—are much less likely to tumble down the ladder in the U. S. than in Canada (44 percent versus 59 percent). A "glass floor" prevents even the least talented offspring of the affluent from falling. There is a blockage in the circulation of the American elite as well, a system-wide hardening of the arteries.

Exhibit A in the case against the American political elites: the U. S. tax code. To call it Byzantine is an insult to medieval Roman administrative prowess. There is one good reason for this complexity: The American tax system is a major instrument of social policy, especially in terms of tax credits to lower-income families, health-care subsidies, incentives for retirement savings, and so on. But there are plenty of bad reasons, too—above all, the billions of dollars' worth of breaks and exceptions resulting from lobbying efforts by the very people the tax system favors.

So fragile is the American political ego that we can't go five minutes without congratulating ourselves on the greatness of our system, yet policy choices exacerbate stuckness.

The American system is also a weak reed when it comes to redistribution. You will have read and heard many times that the United States is one of the most unequal nations in the world. That is true, but only after the impact of taxes and benefits is taken into account. What economists call "market inequality," which exists before any government intervention at all, is much lower—in fact it's about the same as in Germany and France. There is a lot going on under the hood here, but the key point is clear enough: America is unequal because American policy moves less money from rich to poor. Inequality is not fate or an act of nature. Inequality is a choice.

These are facts that should shock America into action. For a nation organized principally around the ideas of opportunity and openness, social stickiness of this order amounts to an existential threat. Although political leaders declare their dedication to openness, the hard issues raised by social inertia are receiving insufficient attention in terms of actual policy solutions. Most American politicians remain cheerleaders for the American Dream, merely offering loud encouragement from the sidelines, as if that were their role. So fragile is the American political ego that we can't go five minutes without congratulating ourselves on the greatness of our system, yet policy choices exacerbate stuckness and ensure decline.

In Britain (where stickiness has historically been an accepted social condition), by contrast, the issues of social mobility and class stickiness have risen to the top of the political and policy agenda. In the previous U.K. government (in which I served as director of strategy to Nick Clegg, the deputy prime minister), we devoted whole Cabinet meetings to the problems of intergenerational mobility and the development of a new national strategy. (One result has been a dramatic expansion in pre-K education and care: Every 3- and 4-year-old will soon be entitled to 30 hours a week for free.) Many of the Cabinet members were schooled at the nation's finest private high schools. A few had hereditary titles. But they pored over data and argued over remedies—posh people worrying over intergenerational income quintiles.

Why is social mobility a hotter topic in the old country? Here is my theory: Brits are acutely aware that they live in a class-divided society. Cues and clues of accent, dress, education, and comportment are constantly calibrated. But this awareness increases political pressure to reduce these divisions. In America, by contrast, the myth of classlessness stands in the way of progress. The everyday folksiness of Americans—which, to be clear, I love—serves as a social camouflage for deep economic inequality. Americans tell themselves and one another that they live in a classless land of open opportunity. But it is starting to ring hollow, isn't it?

III. For black Americans, claims of equal opportunity have, of course, been false from the founding.

They remain false today. The chances of being stuck in poverty are far, far greater for black kids. Half of those born on the bottom rung of the income ladder (the bottom fifth) will stay there as adults. Perhaps even more disturbing, seven out of ten black kids raised in middle-income homes (i.e., the middle fifth) will end up lower down as adults. A boy who grows up in Baltimore will earn 28 percent less simply because he grew up in Baltimore: In other words, this supersedes all other factors. Sixty-six percent of black children live in America's poorest neighborhoods, compared with six percent of white children.

Recent events have shone a light on the black experience in dozens of U. S. cities.

Behind the riots and the rage, the statistics tell a simple, damning story. Progress toward equality for black Americans has essentially halted. The average black family has an income that is 59 percent of the average white family's, down from 65 percent in 2000. In the job market, race gaps are immobile, too. In the 1950s, black Americans were twice as likely to be unemployed as whites. And today? Still twice as likely.

From heeding the call "Go west, young man" to loading up the U-Haul in search of a better job, the instinctive restlessness of America has always matched skills to work, people to opportunities, labor to capital.

Race gaps in wealth are perhaps the most striking of all. The average white household is now thirteen times wealthier than the average black one. This is the widest gap in a quarter of a century. The recession hit families of all races, but it resulted in a wealth wipeout for black families. In 2007, the average black family had a net worth of $19,200, almost entirely in housing stock, typically at the cheap, fragile end of the market. By 2010, this had fallen to $16,600. By 2013—by which point white wealth levels had started to recover—it was down to $11,000. In national economic terms, black wealth is now essentially nonexistent.

Half a century after the passing of the Civil Rights Act, the arc of history is no longer bending toward justice. A few years ago, it was reasonable to hope that changing attitudes, increasing education, and a growing economy would surely, if slowly, bring black America and white America closer together. No longer. America is stuck.

IV. The economy is also getting stuck.

Labor productivity growth, measured as growth in output per hour, has averaged 1.6 percent since 1973. Male earning power is flatlining. In 2014, the median full-time male wage was $50,000, down from $53,000 in 1973 (in the dollar equivalent of 2014). Capital is being hoarded rather than invested in the businesses of the future. U. S. corporations have almost $1.5 trillion sitting on their balance sheets, and many are busily buying up their own stock. But capital expenditure lags, hindering the economic recovery.

New-business creation and entrepreneurial activity are declining, too. As economist Robert Litan has shown, the proportion of "baby businesses" (firms less than a year old) has almost halved since the late 1970s, decreasing from 15 percent to 8 percent—the hallmark of "a steady, secular decline in business dynamism." It is significant that this downward trend set in long before the Great Recession hit. There is less movement between jobs as well, another symptom of declining economic vigor.

Americans are settling behind their desks—and also into their neighborhoods. The proportion of American adults moving house each year has decreased by almost half since the postwar years, to around 12 percent. Long-distance moves across state lines have as well. This is partly due to technological advances, which have weakened the link between location and job prospects, and partly to the growth of economic diversity in cities; there are few "one industry" towns today. But it is also due to a less vibrant housing market, slower rates of new business creation, and a lessening in Americans' appetite for disruption, change, and risk.

This geographic settling is at odds with historic American geographic mobility. From heeding the call "Go west, young man" to loading up the U-Haul in search of a better job, the instinctive restlessness of America has always matched skills to work, people to opportunities, labor to capital. Rather than waiting for help from the government, or for the economic tide to turn back in their favor, millions of Americans changed their life prospects by changing their address. Now they are more likely to stay put and wait. Others, especially black Americans, are unable to escape the poor neighborhoods of their childhood. They are, as the title of an influential book by sociologist Patrick Sharkey puts it, Stuck in Place.

There are everyday symptoms of stuckness, too. Take transport. In 2014, Americans collectively spent almost seven billion hours stuck motionless in traffic—that's a couple days each. The roads get more jammed every year. But money for infrastructure improvements is stuck in a failing road fund, and the railophobia of politicians hampers investment in public transport.

Whose job is it to do something about this? The most visible symptom of our disease is the glue slowly hardening in the machinery of national government. The last two Congresses have been the least productive in history by almost any measure chosen, just when we need them to be the most productive. The U. S. political system, with its strong separation among competing centers of power, relies on a spirit of cross-party compromise and trust in order to work. Good luck there.

V. So what is to be done?

As with anything, the first step is to admit the problem. Americans have to stop convincing themselves they live in a society of opportunity. It is a painful admission, of course, especially for the most successful. The most fervent believers in meritocracy are naturally those who have enjoyed success. It is hard to acknowledge the role of good fortune, including the lottery of birth, when describing your own path to greatness.

There is a general reckoning needed. In the golden years following World War II, the economy grew at 4 percent per annum and wages surged. Wealth accumulated. The federal government, at the zenith of its powers, built interstates and the welfare system, sent GIs to college and men to the moon. But here's the thing: Those days are gone, and they're not coming back. Opportunity and growth will no longer be delivered, almost automatically, by a buoyant and largely unchallenged economy. Now it will take work.

The future success of the American idea must now be intentional.

Entrepreneurial, mobile, aspirational: New Americans are true Americans. We need a lot more of them.

There are plenty of ideas for reform that simply require will and a functioning political system. At the heart of them is the determination to think big again and to vigorously engage in public investment. And we need to put money into future generations like our lives depended on it, because they do: Access to affordable, effective contraception dramatically cuts rates of unplanned pregnancy and gives kids a better start in life. Done well, pre-K education closes learning gaps and prepares children for school. More generous income benefits stabilize homes and help kids. Reading programs for new parents improve literacy levels. Strong school principals attract good teachers and raise standards. College coaches help get nontraditional students to and through college. And so on. We are not lacking ideas. We are lacking a necessary sense of political urgency. We are stuck.

But we can move again if we choose.

In addition to a rejuvenation of policy in all these fields, there are two big shifts required for an American twenty-first-century renaissance: becoming open to more immigration and shifting power from Washington to the cities.

VI. America needs another wave of immigration.

This is in part just basic math: We need more young workers to fund the old age of the baby boomers. But there is more to it than that. Immigrants also provide a shot in the arm to American vitality itself. Always have, always will. Immigrants are now twice as likely to start a new business as native-born Americans. Rates of entrepreneurialism are declining among natives but rising among immigrants.

Immigrant children show extraordinary upward-mobility rates, shooting up the income-distribution ladder like rockets, yet by the third or fourth generation, the rates go down, reflecting indigenous norms. Among children born in Los Angeles to poorly educated Chinese immigrants, for example, an astonishing 70 percent complete a four-year-college degree. As the work of my Brookings colleague William Frey shows, immigrants are migrants within the U. S., too, moving on from traditional immigrant cities—New York, Los Angeles—to other towns and cities in search of a better future. Entrepreneurial, mobile, aspirational: New Americans are true Americans. We need a lot more of them.

This makes a mockery of our contemporary political "debates" about immigration reform, which have become intertwined with race and racism. Some Republicans tap directly into white fears of an America growing steadily browner. More than four in ten white seniors say that a growing population of immigrants is a "change for the worse"; half of white boomers believe immigration is "a threat to traditional American customs and values." But immigration delves deeper into the question of American identity than it does even issues of race. Immigrants generate more dynamism and aspiration, but they are also unsettling and challenging. Where this debate ends will therefore tell us a great deal about the trajectory of the nation. An America that closes its doors will be an America that has chosen to settle rather than grow, that has allowed security to trump dynamism.

VII. The second big shift needed to get America unstuck is a revival of city and state governance.

Since the American Dream is part of the national identity, it seems natural to look to the national government to help make it a reality. But cities are now where the American Dream will live or die. America's hundred biggest metros are home to 67 percent of the nation's population and 75 percent of its economy. Americans love the iconography of the small town, even at the movies—but they watch those movies in big cities.

Powerful mayors in those cities have greater room for maneuvering and making an impact than the average U. S. senator. Even smaller cities and towns can be strongly influenced by their mayor.

There are choices to be made. Class divisions are hardening. Upward mobility has a very weak pulse. Race gaps are widening.

The new federalism in part is being born of necessity. National politics is in ruins, and national institutions are weakened by years of short-termism and partisanship. Power, finding a vacuum in D. C., is diffusive. But it may also be that many of the big domestic-policy challenges will be better answered at a subnational level, because that is where many of the levers of change are to be found: education, family planning, housing, desegregation, job creation, transport, and training. Amid the furor over Common Core and federal standards, it is important to remember that for every hundred dollars spent on education, just nine come from the federal government.

We may be witnessing the end of many decades of national-government dominance in domestic policy-making (the New Deal, Social Security, Medicare, welfare reform, Obamacare). The Affordable Care Act is important in itself, but it may also come to have a place in history as the legislative bookend to a long period of national-policy virtuosity.

The case for the new federalism need not be overstated. There will still be plenty of problems for the national government to fix, including, among the most urgent, infrastructure and nuclear waste. The main tools of macroeconomic policy will remain the Federal Reserve and the federal tax code. But the twentieth-century model of big federal social-policy reforms is in decline. Mayors and governors are starting to notice, and because they don't have the luxury of being stuck, they are forced to be entrepreneurs of a new politics simply to survive.

VIII. It is possible for America to recover its earlier dynamism, but it won't be easy.

The big question for Americans is: Do you really want to? Societies, like people, age. They might also settle down, lose some dynamism, trade a little less openness for a little more security, get a bit stuck in their ways. Many of the settled nations of old Europe have largely come to terms with their middle age. They are wary of immigration but enthusiastic about generous welfare systems and income redistribution. Less dynamism, maybe, but more security in exchange.

America, it seems to me, is not made to be a settled society. Such a notion runs counter to the story we tell ourselves about who we are. (That's right, we. We've all come from somewhere else, haven't we? I just got here a bit more recently.) But over time, our narratives become myths, insulating us from the truth. For we are surely stuck, if not settled. And so America needs to decide one way or the other. There are choices to be made. Class divisions are hardening. Upward mobility has a very weak pulse. Race gaps are widening. The worst of all worlds threatens: a European class structure without European welfare systems to dull the pain.

Americans tell themselves and the world that theirs is a society in which each and all can rise, an inspiring contrast to the hereditary cultures from which it sprang. It's one of the reasons I'm here. But have I arrived to raise my children here just in time to be stuck, too? Or will America be America again?

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

When California passed its 2016 budget late last month, it joined a growing list of states that have recently adopted or expanded state versions of the federal Earned Income Tax Credit (EITC). First enacted in 1975, the EITC has become one of the country’s most effective antipoverty programs. We estimate that the federal EITC keeps millions of individuals and children out of poverty each year, reducing the national poverty rate by several percentage points. Others have shown how the EITC creates a strong incentive to work and works as a powerful tool for reducing income inequality.

For an unmarried worker with one child in 2015, the federal EITC works like this: Up to her first $9,880 earned, the worker receives a tax credit equal to 34 cents on the dollar, for a maximum credit value of $3,359. The credit is reduced by 16 cents for each dollar earned beginning at $18,110, eventually phasing out at $39,100 in earnings. Phase-in and phase-out rates and ranges depend on a worker’s filing status and number of dependents claimed. Importantly, the EITC is refundable; a filer can still claim any credit in excess of her tax liability, contributing to refunds that can represent double-digit shares of annual income for lower-paid workers.

Of the 26 states and the District of Columbia with their own EITCs, most have structured their programs to mirror the federal EITC, by simply matching some percentage of the federal credit in a given tax year (see map). This year, Massachusetts, New Jersey, and Rhode Island all increased their state EITCs’ matching percentages. In three states, the EITC is non-refundable, making it a less effective incentive for very low-income workers (Maine this year made its credit refundable). California’s EITC joins a couple of others that, while still refundable, vary in the degree to which they mirror the federal credit based on filing status and income.

Through our work maintaining Brookings’ EITC Interactive, we hear regularly from stakeholders around the country engaged in efforts to expand the EITC and increase local participation to strengthen low-income families and communities. Although it is difficult to determine uptake rates locally, there are several factors associated with participation. Self-employed workers are less likely to claim the credit, as are workers with low English proficiency, and those who do not claim any dependents. The availability of tax preparation assistance tends to increase participation rates. For groups who hope to expand access to the EITC in their communities, these considerations are a good place to start.

To be sure, the EITC is not a silver bullet. Because it is explicitly tied to work effort, the credit does not support low-income families who can’t find work. And because states must balance their budgets, many have had difficulty sustaining their EITCs during periods of economic downturn. (Several of the recent state EITC expansions actually represent the restoration of benefits following drastic cuts during the Great Recession.) Additionally, the federal EITC and its state analogues provide only modest support to workers who do not claim any dependents on their tax return. As such, policy makers should consider state EITCs strong complements to other interventions, such as the growing number of increases in the minimum wage occurring in states and cities.

Nevertheless, the EITC remains one of the best tools we have to fight poverty. Despite bipartisan support for the federal EITC, it is unlikely to be expanded anytime soon. In that light, recent state EITC expansions may be helping to create a more responsive, sub-national safety net that better reflects a large and diverse nation where local priorities and needs differ markedly.

After years of irresponsible fiscal management, Puerto Rico has few good options to address its growing debt crisis. But in most tales of bad behavior, there comes a point where continued punishment for past mistakes becomes counterproductive. We're reaching that point on Puerto Rico, and the Barack Obama administration has put forward a sensible new approach. 

(Citigroup, my employer, has various business relationships with Puerto Rico, including serving as underwriter and market maker in various securities. I've had no involvement in those activities, and this column represents my personal views, not those of Citi.)

Puerto Rico's population and its economy are about 10 percent smaller than they were a decade ago. The poverty rate is 45 percent, only about 40 percent of adults are in the labor force, and unemployment is more than 11 percent. 

Given these dire economic indicators, it's not surprising that Puerto Rico has a serious debt problem. At this point, the territory's total liabilities amount to more than 160 percent of the economy, and debt service is projected to be more than a third of government revenue. Over the next five years, the fiscal deficit looks to be $28 billion, and although the Puerto Rican government has proposed aggressive policy actions, these could, at best, only cut the deficit in half. Because the territory's fiscal dynamic is unsustainable, its uninsured debt is selling at discounts of 30 to 70 percent. 

Something has to give. Which brings us to the White House's plan.

The first imperative is to restore economic growth. For this, there are no magic bullets, but one useful strategy is to extend the Earned Income Tax Credit to Puerto Rico. The EITC is one of the most powerful, market-friendly mechanisms for encouraging labor force participation, and its absence in Puerto Rico makes no sense.

The Obama administration also proposes removing an anomaly in the Medicaid system. If Medicaid treated Puerto Rico in the same way as it does the 50 states, the federal government would pay for an estimated 83 percent of its Medicaid costs. But because Medicaid payments to the territory are capped, the federal government has generally paid only 15 to 20 percent. In addition, temporary Medicaid payments enacted as part of the Affordable Care Act are almost exhausted, posing a near-term threat to Puerto Rico's Medicaid program.

Establishing an EITC in Puerto Rico and adjusting the share of Medicaid payments paid by the federal government make sense from a fairness perspective. The EITC piece would encourage work, and the Medicaid component would attenuate fiscal pressure on the island. These steps would, though, come at a cost to the federal budget, probably in the billions of dollars per year. The administration should clarify both the amounts involved and how they would be financed. 

The island's fiscal governance also needs to be strengthened. Its accounting systems have been shoddy, and revenue estimates have been overly rosy. A period of external oversight is appropriate, to improve transparency and budgetary rigor. 

Finally, there's the hard question of what to do about the existing overhang of debt. Write-offs are inevitable; the only question is how to do them in a structured and timely way. We have bankruptcy laws precisely to handle this sort of situation, which would otherwise involve overlapping negotiations with multiple creditors (Puerto Rico has 18 different debt issuers and 20 creditor committees) and probably extended lawsuits. 

At the very least, Congress should extend Chapter 9 bankruptcy laws to Puerto Rico's cities and public corporations. Municipalities in the states enjoy this protection, and there's no reason to treat cities in Puerto Rico differently than those in Florida or Texas. This step would cover about a third of the territory's debt. 

The more controversial question, though, is whether Puerto Rico's government should also have access to bankruptcy protection. State governments do not, but the administration proposes that territories such as Puerto Rico should. 

Bankruptcy would not necessarily mean that less debt would be repaid. So it is not clear that the traditional argument against bankruptcy protection -- that it would raise future borrowing costs -- carries much force. Negotiated write-offs and default would have largely the same effect, but would probably take longer and be messier. Among the options left, the administration's is the least bad. 

The plan requires legislation, and in today's polarized Congress, that's a daunting prospect. But as former Treasury Secretary Tim Geithner once emphasized, in a crisis, "plan beats no plan." the administration has one. Its congressional opponents don't.

Editor's Note: this op-ed originally appeared on Bloomberg View.

*A slightly modified version of this commentary appeared in The Springfield News-Leader on October 24, 2004.

The Missouri gubernatorial race is going down to the wire, and guess what? Contentious social and moral issues are predominating.

Last week Republican Matt Blunt questioned McCaskill's values, saying his stand against gay marriage matched the values of mainstream Missourians.

For her part, McCaskill, the Democratic state auditor, has parried Blunt on gays, guns, and abortion by insisting that Republicans don't have a lock on values just because Democrats like her don't wear religion on their sleeves.

Look for more sniping on gays, guns, and abortion as the campaigns careen toward election day.

Which would be too bad.

Missouri—and particularly the Springfield region—needs to talk about some other things this fall.

In a major statewide report, "Growth in the Heartland: Challenges and Opportunities for Missouri," after all, we argued that Missouri today faces an outright land-use, environmental, and competitive crisis that has little to do with gay marriage or concealed-carry gun rules.

The crisis is not new—we described it two years ago—but the fact remains that Missouri's chaotic style of low-density development is gobbling up the state's rural heritage, gutting towns and cities, and exacting a heavy toll on Missourians' pocketbooks and quality of life just when the state needs to compete at a higher level on exactly those factors.

Just look around the Springfield area:

Forty-five percent of the region's growth in the 1990s took place in the unincorporated "open country," the exurban places often least equipped to manage it.

Strip malls and home sites are chewing up the region's beautiful Ozarks scenery.

And all the while newcomers are flocking to small outlying towns like Willard, Republic, Clever, Niza, and Ozark—all of which hit "hypergrowth" in the 1990s and struggle to keep up.

As to the results, they have been predictably mixed: New jobs and vitality have been accompanied by the water-quality problems that have fouled Lake Taneycomo and Table Rock Lake. Taxes are increasing as local governments strain to provide the necessary roads, services, or sewer hook-ups. And with more sprawl coming, more traffic and mini-malls could soon undercut the region's reputation as the quaint heartland of rural America.

Why do these trends matter? For some the concern is cultural. They fear the state is losing its rural heritage. For others the threat is environmental. They are disturbed by the degradation of the Ozark lakes and other nearby natural areas.

However, for us the concern is mostly economic: By remaining virtually laissez faire on growth and development issues, we fear the Show Me State is undercutting its ability to parlay its very real assets into a broader prosperity.

Spread-out development patterns, for example, raise costs in the state for businesses and individual taxpayers. That's because highly dispersed development often increases the capital and operations costs of roads, sewer lines, schools, and police or fire services.

Similarly, Missouri's dispersed development adds to the size of the state's enormous—and crumbling—highway system. Missouri taxpayers consequently struggle with a maintenance backlog that will require half a billion dollars a year over the next 10 years—some $200 million more than current finding will provide.

And likewise, we suspect that the state's spread-out, low-quality development diminishes Missouri's appeal to highly educated workers—that critical factor if the state is going to appeal to entrepreneurs, well-educated retirees, and leading-edge techies and scientists.

This is especially important in the Springfield region, where the recent boom has clearly been built on the appeal of the region's improving downtown and cultural facilities, high quality of life, and stunning natural beauty.

And so we say it again—Missouri and the gubernatorial candidates need to face up to some tough realities this fall:

• Missouri can't afford to keep sprawling, even with tax revenues stronger this year. So Blunt and McCaskill need to tell Missourians how they will foster more efficient, less chaotic growth that doesn't break the bank

Missouri, in sum, stands at a crossroads.

Other heartland states, like Michigan and Pennsylvania, now recognize the links between educated workers, strong urban and rural centers, and economic competitiveness—and are taking action. Missouri needs to face up to the challenge.

Similarly, other states are moving to reap the fiscal benefits of nudging development into more sensible patterns, so Missouri should think about that too.

As to the agitations of wedge issues like abortion and concealed weapons or gay marriage, Missourians should take them in stride. "Values" are important, sure, but at the same time, there's a land-use and competitive crisis underway in Missouri that both the candidates and voters ignore at their peril this election.

Earlier this month, Missouri voters overwhelmingly rejected a 10-year, 3/4 cent sales tax increase to boost statewide transportation investment. With local referendums an increasingly popular method to raise transportation funding in an era of federal uncertainty, the result has lessons for Missouri’s transportation interests and the country as a whole.

Like many states, Missouri has a clear infrastructure deficit. A legislatively-mandated citizens committee found the state needs an additional $600 million to $1 billion in investment per year. The problem is finding the money. Outside of federal funds, the state primarily relies on a 17.3 cent gasoline tax and local property taxes to fund transportation projects, plus location-specific revenue streams like a half-cent sales tax in St. Louis city and county. Yet with Missouri residents driving less in recent years—down 5 percent per capita between 2000 and 2012-—there is less money available to fund critical projects.

This vote offered one remedy. The statewide bump in sales tax would’ve generated upwards of $5 billion over the ten-year period. The new monies would go to 800 projects across Missouri, primarily for roadways. The governance was a similarly unequal split, with the state department of transportation directly controlling all but 10 percent of the new revenue.

And this is where the referendum’s problems become clear. While each of the state’s seven transportation districts managed their own project list, there was no guarantee local sales taxes would be spent on local projects. There were also legitimate questions whether a heightened focus on roadways made sense in the face of falling statewide driving. This was at the heart of the opposition argument, led by Missourians for Better Transportation Solutions.

In many ways, the Missouri results reflect what happened in a failed 2012 Atlanta referendum. That transportation package contained a hodgepodge of road and rail projects, barely increased connectivity across the sprawling metro region and couldn’t align local interest groups. Much like Missouri, Atlanta has clear transportation needs—but voters sensed the current plan wouldn’t do enough to adequately improve their commutes and livability.

As Missouri’s transportation leaders regroup, they’d be wise to follow the “economy-first” lesson of successful referendums in places like Los Angeles, Denver and Oklahoma City. The common thread in all three was a great job proving the need for greater infrastructure investment. But as my colleagues outlined in a recent report, they also captured how transportation could support industrial growth and metro-wide economic health. Americans have proven time and again they’ll pay for transportation projects, but they want to know what they’re getting and how it will benefit their communities.

In this sense, I’m heartened by a recent Kansas City Star editorial related to their failed streetcar vote the same day. Even with a failed vote, the metro area still needs a better infrastructure network. The key is for public, private and civic leaders to continue working with the public to determine which transportation investments will best support regional economic growth for decades to come.

Ballot measures may fail, but they’ll always provide lessons to improve the plans that will pass.

Editor's note: This article appears in the April 2015 issue of Global Forum. Click here to view the full publication.

Since passage of the Affordable Care Act in 2010, the last several years have seen a groundswell in physician payment and delivery reforms designed to achieve higher value health care through incentivizing higher quality care and lower overall costs. Accountable care models, for example, are achieving marked progress by realigning provider incentives toward greater risk-sharing and increased payments and shared savings with measured improvements in quality and cost containment. Medical homes are introducing greater care coordination and team-based care management, while the use of episode-based or bundled payments is removing perverse incentives that reward volume and intensity.

These reforms are coming just as the number of highly targeted, highly priced treatments continues to expand. The U.S. Food and Drug Administration (FDA) approved a decade-high 41 novel new drugs in 2014, many of them targeted therapies approved on the basis of increasingly sophisticated progress in genomics and the understanding of disease progression. In areas like oncology, such targeted treatments have grown as a percentage of global oncology market size from 11% in 2003 to 46% in 2013. New brand specialty drug spending in the U.S. is estimated to have been $7.5 billion in 2013, or 69% of total new drug spending. The growing prevalence of these drugs and their cost to the health system are setting the stage for significant flashpoints between industry, payers, and providers, seen most clearly in the debate over hepatitis C treatment costs that roiled stakeholder interactions for most of the past year. 

More of these targeted treatments are in the development pipeline, and a growing number of public policy efforts taking shape in 2015 are focused on accelerating their availability. The House of Representatives' 21st Century Cures Initiative, for example, has released a slew of legislative proposals aimed at promoting breakthrough innovation by increasing the efficiency of drug development and regulatory review. These efforts have significant downstream implications for the pace at which targeted and specialty therapies will become available, their associated costs, and the growing importance of demonstrating value in the postmarket setting.

As payers and providers continue their push toward increased value-based care, more innovative models for connecting such reforms to drug development are needed. Earlier collaboration with industry could enable more efficient identification of unmet need, opportunities to add value through drug development, and clearer input on the value proposition and evidentiary thresholds needed for coverage. Equally important will be unique public-private collaborations that invest in developing a better postmarket data infrastructure that can more effectively identify high value uses of new treatments and support achieving value through new payment reforms.

Stronger collaboration could also improve evidence development and the coverage determination process after a targeted  treatment has gained regulatory approval. Facilitated drug access programs like those proposed by the Medicare Administrative Contractor Palmetto GBA create access points for patients to receive targeted anti-cancer agents off-label while payers and industry gather important additional outcomes data in patient registries. More systematic and efficient use of policies like Medicare's Coverage with Evidence Development (CED), which allows for provisional coverage for promising technologies or treatments while evidence continues to be collected, could enable industry and payers to work together to learn about a medical product's performance in patient populations not typically represented in clinical studies. A CED-type model could be especially useful for certain specialty drugs: data collected as a condition of payment could help payers and providers develop evidence from actual practice to improve treatment algorithms, increase adherence, and improve outcomes. 

Finally, collaborations that support stronger postmarket data collection can also support novel drug payment models that further reward value. Bundled payments that include physician-administered drugs, for example, could encourage providers to increase quality while also incentivizing manufacturers to help promote evidence-based drug use and lower costs for uses that generate low value. Outcomes-based purchasing contracts that tie price paid to a medical product's performance could be another promising approach for high-expense treatment with clearly defined and feasibly measured outcomes.

Many of these ideas are not new, but as manufacturers, payers, providers, and patients move into an increasingly value-focused era of health care, it is clear that they must work together to find new ways to both promote development of promising new treatments while also making good on the promise of value-based health care reforms.

Demand for more walkable, mixed use neighborhoods is growing across the United States. However, the challenges associated with fi nancing these developments are allowing much of this demand to go unmet. This paper discusses how more, and more upfront, patient equity in walkable projects—from various sources and providers—would facilitate their development, and yield high returns over the long term. The paper also examines how patient equity contributed to the success of several such developments built over the past 15 years, illustrating untapped potential. Finally, it notes the role the public sector can play in providing patient equity investments.

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