For several years, President Obama has operated under a set of assumptions about the Middle East: First, there could be no return of U.S. ground troops in sizeable numbers to the region; and second, the United States had no interests in the region great enough to justify such a renewed commitment. The crises in the Middle East could be kept localized. The core elements of the world order would not be affected, and America’s own interests would not be directly threatened.

These assumptions could have been right, but instead they have proven to be wrong. The combined crises of Syria, Iraq, and the threat posed by the Islamic State (or ISIS) have not been contained. ISIS itself has proven both durable and capable, as the attacks in Paris showed. The Syrian conflict—with the resulting refugee flows—is destabilizing Lebanon and Jordan; it has put added pressure on Turkey’s already tenuous democracy; and it has exacerbated the acute conflict between Sunni and Shiite across the region. The multi-sided war in the Middle East has now ceased to be a strictly Middle Eastern problem. It has become a European problem, as well. The crisis on the periphery, in short, has now spilled over into the core.

Does this not call for a reassessment of the policies that have so far been tried in Syria and Iraq? Have not events in the Middle East, and now in Europe, reached the point where significant interests are at stake, thereby requiring a more substantial response by the United States?

Read Robert Kagan's more in-depth article on the subject in the Wall Street Journal.

State and local bond finance represents a powerful but underutilized tool for future clean energy investment.

For 100 years, the nation’s state and local infrastructure finance agencies have issued trillions of dollars’ worth of public finance bonds to fund the construction of the nation’s roads, bridges, hospitals, and other infrastructure—and literally built America. Now, as clean energy subsidies from Washington dwindle, these agencies are increasingly willing to finance clean energy projects, if only the clean energy community will embrace them.

So far, these authorities are only experimenting. However, the bond finance community has accumulated significant experience in getting to scale and knows how to raise large amounts for important purposes by selling bonds to Wall Street. The challenge is therefore to create new models for clean energy bond finance in states and regions, and so to establish a new clean energy asset class that can easily be traded in capital markets. To that end, this brief argues that state and local bonding authorities and other partners should do the following:

• Establish mutually useful partnerships between development finance experts and clean energy officials at the state and local government levels
• Expand and scale up bond-financed clean energy projects using credit enhancement and other emerging tools to mitigate risk and through demonstration projects
• Improve the availability of data and develop standardized documentation so that the risks and rewards of clean energy investments can be better understood
• Create a pipeline of rated and private placement deals, in effect a new clean energy asset class, to meet the demand by institutional investors for fixed-income clean energy securities

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On July 20 and 21, defense ministers from several nations will gather in Washington, D.C. at the invitation of U.S. Secretary of Defense Ash Carter. The meeting will bring together representatives from countries working to confront and defeat the Islamic State (or ISIL). French Defense Minister Jean-Yves Le Drian will be among those at the summit discussing how to accelerate long-term efforts to fight ISIL in Iraq and Syria. The close relationship between France and the United States has provided a solid base for security cooperation for decades, and in recent years, France has become one of America’s strongest allies in fighting terrorism and a prominent member of the international coalition to defeat ISIL.

On July 20, the Foreign Policy program at Brookings hosted Minister Le Drian for a discussion on French and U.S. cooperation as the two countries face multiple transnational security threats. Since becoming France’s defense minister in 2012, Le Drian has had to address numerous new security crises emerging from Africa, the Middle East, and within Europe itself. France faced horrific terrorist attacks on its own soil in January and November 2015 and remains under a state of emergency with its armed forces playing an active role in maintaining security both at home and abroad. Le Drian recently authored “Qui est l’ennemi?” (“Who is the enemy?”, Editions du Cerf, May 2016), defining a comprehensive strategy to address numerous current threats.

Join the conversation on Twitter using #USFrance

Video

• Introduction and featured speaker
• Discussion
• Introduction et conférencier invité
• Débat

Transcript

• Uncorrected Transcript (.pdf)

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• 20160720_france_defense_transcript

With only a few months remaining before the 2004 elections, national party committees continue to demonstrate financial strength and noteworthy success in adapting to the more stringent fundraising rules imposed by the Bipartisan Campaign Reform Act (BCRA). A number of factors, including the deep partisan divide in the electorate, the expectations of a close presidential race, and the growing competition in key Senate and House races, have combined with recent party investments in new technology and the emergence of the Internet as a major fundraising tool to produce what one party chairman has described as a "perfect storm" for party fundraising.¹ Consequently, both national parties have exceeded the mid-year fundraising totals achieved in 2000, and both approach the general election with substantial amounts of money in the bank.

After eighteen months of experience under the new rules, the national parties are still outpacing their fundraising efforts of four years ago. As of June 30, the national parties have raised $611.1 million in federally regulated hard money alone, as compared to $535.6 million in hard and soft money combined at a similar point in the 2000 election cycle. The Republicans lead the way, taking in more than $381 million as compared to about $309 million in hard and soft money by the end of June in 2000. The Democrats have also raised more, bringing in $230 million as compared to about $227 million in hard and soft money four years ago. Furthermore, with six months remaining in the election cycle, both national parties have already raised more hard money than they did in the 2000 election cycle.² In fact, by the end of June, every one of the Democratic and Republican national party committees had already exceeded its hard money total for the entire 2000 campaign.³

This surge in hard money fundraising has allowed the national party committees to replace a substantial portion of the revenues they previously received through unlimited soft money contributions. Through June, these committees have already taken in enough additional hard money to compensate for the $254 million of soft money that they had garnered by this point in 2000, which represented a little more than half of their $495 million in total soft money receipts in the 2000 election cycle.

View the accompanying data tables (PDF - 11.4 KB)

¹Terrence McAuliffe, Democratic National Committee Chairman, quoted in Paul Fahri, "Small Donors Grow Into Big Political Force," Washington Post, May 3, 2004, p. A11.
²In 2000, the Republican national party committees raised $361.6 million in hard money, while the Democratic national committees raised $212.9 million. These figures are based on unadjusted data and do not take into account any transfers of funds that may have taken place among the national party committees.
³The election cycle totals for 2000 can be found in Federal Election Commission, "FEC Reports Increase in Party Fundraising for 2000," press release, May 15, 2001. Available at http://www.fec.gov/press/press2001/051501partyfund/051501partyfund.html (viewed July 28, 2004).

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The 2008 elections showcased the power of the Internet to generate voter enthusiasm, mobilize volunteers and increase small-donor contributions. After the political world has been arguing about campaign finance policy for decades, the digital revolution has altered the calculus of participation.

On January 14, a joint project of the Campaign Finance Institute, American Enterprise Institute and the Brookings Institution unveiled a new report that seeks to change the ongoing national dialogue about money in politics. At this event, the four authors of the report will detail their findings and recommendations. Relying on lessons from the record-shattering 2008 elections and the rise of Internet campaigning, experts will present a new vision of how campaign finance and communications policy can help further democracy through broader participation.

Video

• Thomas Mann
• Michael Malbin
• Anthony Corrado
• Norm Ornstein

Audio

• Campaign Reform in the Networked Age: Fostering Participation through Small Donors and Volunteers

Transcript

• Transcript (.pdf)

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• 20090114_campaign_finance

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On July 20 and 21, defense ministers from several nations will gather in Washington, D.C. at the invitation of U.S. Secretary of Defense Ash Carter. The meeting will bring together representatives from countries working to confront and defeat the Islamic State (or ISIL). French Defense Minister Jean-Yves Le Drian will be among those at the summit discussing how to accelerate long-term efforts to fight ISIL in Iraq and Syria. The close relationship between France and the United States has provided a solid base for security cooperation for decades, and in recent years, France has become one of America’s strongest allies in fighting terrorism and a prominent member of the international coalition to defeat ISIL.

On July 20, the Foreign Policy program at Brookings hosted Minister Le Drian for a discussion on French and U.S. cooperation as the two countries face multiple transnational security threats. Since becoming France’s defense minister in 2012, Le Drian has had to address numerous new security crises emerging from Africa, the Middle East, and within Europe itself. France faced horrific terrorist attacks on its own soil in January and November 2015 and remains under a state of emergency with its armed forces playing an active role in maintaining security both at home and abroad. Le Drian recently authored “Qui est l’ennemi?” (“Who is the enemy?”, Editions du Cerf, May 2016), defining a comprehensive strategy to address numerous current threats.

Join the conversation on Twitter using #USFrance

Video

• Introduction and featured speaker
• Discussion
• Introduction et conférencier invité
• Débat

Transcript

• Uncorrected Transcript (.pdf)

Event Materials

• 20160720_france_defense_transcript

Since its 50th anniversary in 1994, the World Bank has been led by four presidents: Lewis Preston until his untimely death in 1995; then James Wolfensohn, who gave the institution new energy, purpose and legitimacy; followed by Paul Wolfowitz, whose fractious management tossed the World Bank into deep crisis; and most recently, Robert Zoellick, who will be remembered for having stabilized the bank and provided effective leadership during its remarkably swift and strong response to the global financial crisis.

Throughout these years of ups and downs in the bank’s leadership, standing and lending, the overall trend of its global role was downhill. While it remains one of the world’s largest multilateral development finance institutions, its position relative to other multilateral financing mechanisms is now much less prominent. Other multilateral institutions have taken over key roles. For example, the European Union agencies and the regional development banks have rapidly expanded their portfolios, and new “vertical funds” such as the Global Fund for AIDS, Tuberculosis and Malaria have become major funding vehicles. At the same time, according to a 2011 OECD Development Assistance Committee report multilateral aid has declined as a share of total aid. Meanwhile, non-governmental aid flows have dramatically increased, including those from major foundations like the Bill and Melinda Gates Foundation, but also from new internet-based channels bundling small individual donations, such as Global Giving. The World Bank— which 20 years ago was still the biggest and most powerful global development agency and hence a ready target for criticism— today is just one of the many institutions that offer for development to the poor and emerging market economies.

Against this backdrop, the World Bank, its members and Dr. Kim face three options in its long-term trajectory over the next 10 to 20 years: 1) the bank can continue on its current path of gradual decline; 2) it might be radically scaled back and eventually eliminated, as other aid channels take over; or 3) it can dramatically reinvent itself as a global finance institution that bundles resources for growing global needs.

There is no doubt in this author’s mind that the World Bank should remain a key part of the global governance architecture, but that requires that the new president forge an ambitious long-term vision for the bank – something that has been lacking for the last 30 years – and then reform the institution and build the authorizing environment that will make it possible to achieve the vision.

Option 1: “Business as Usual” = Continued Gradual Decline

The first option, reflecting the business-as-usual approach that characterized most of the Zoellick years of leadership will mean that the bank will gradually continue to lose in scope, funding and relevance. Its scope will be reduced since the emerging market economies find the institution insufficiently responsive to their needs. They have seen the regional development banks take on increasing importance, as reflected in the substantially greater capital increases in recent years for some of these institutions than for the World Bank in relative terms (and in the case of the Asian Development Bank, even in absolute terms). And emerging market economies have set up their own thriving regional development banks without participation of the industrial countries, such as the Caja Andina de Fomento (CAF) in Latin America and the Eurasian Development Bank in the former Soviet Union. This trend will be reinforced with the creation of a “South Bank” or “BRIC Bank”, an initiative that is currently well underway.

At the same time, the World Bank’s soft loan window, the International Development Association (IDA), will face less support from industrial countries going through deep fiscal crises, heightened competition from other concessional funds, and a perception of reduced need, as many of the large and formerly poor developing countries graduate to middle-income status. It is significant that for the last IDA replenishment much of the increase in resources was due to its growing reliance on advance repayments made by some of its members and commitments against future repayments, thus in effect mortgaging its future financial capacity. The World Bank’s status as a knowledge leader in development will also continue to be challenged with the rise of research from developing countries and growing think tank capacity, as well as a proliferation of private and official agencies doling out advice and technical assistance.

As a result, under this option, over the next 10 to 20 years the World Bank will likely become no more than a shadow of the preeminent global institution it once was. It will linger on but will not be able to contribute substantially to address any of the major global financial, economic or social challenges in the future.
 
Option 2: “The Perfect Storm” = Breaking Up the World Bank

In 1998, the U.S. Congress established a commission to review and advise on the role of the international financial institutions. In 2000, the commission, led by Professor Allan Meltzer, released its recommendations, which included far-reaching changes for the International Monetary Fund and the World Bank, most of them designed to reduce the scope and financial capacities of these institutions in line with the conservative leanings of the majority of the commission’s members. For the World Bank, the “Meltzer Report” called for much of its loan business and financial assets to be devolved to the regional development banks, in effect ending the life of the institution as we know it. The report garnered some attention when it was first issued, but did not have much impact in the way the institution was run in the following 10 years.

In 2010, the U.S. Senate Foreign Relations Committee released a report on the international financial institutions, which called on them to aim toward “succeeding in their development and economic missions and thereby putting them out of business”. However, it did not recommend a drastic restructuring of the multilateral development banks, and instead argued strongly against any dilution of the U.S. veto right, its lock on leadership selection, and its voting share at the IMF and World Bank. While not dramatic in its short-term impact, these recommendations were likely a strong factor in the subsequent decisions made by the Obama administration to oppose a substantial increase in contributions by emerging markets during the latest round of capital increase at the World Bank to push for an American to replace Robert Zoellick as World Bank president. These actions reinforced for emerging market countries that the World Bank would not change sufficiently and quickly enough to serve their interests, and thus helped create the momentum for setting up a new “South Bank.”

While there seems to be no imminent risk of a break-up of the World Bank along the lines recommended by the Meltzer Report, the combination of fiscal austerity and conservative governments in key industrial countries, compounded by a declining interest of the emerging market countries in sustaining the institution’s future, could create the perfect storm for the bank. Specifically, as governments face constrained fiscal resources, confront the increasing fragmentation of the multilateral aid architecture, and take steps to consolidate their own aid agencies, they might conclude that it would be more efficient and fiscally prudent to rationalize the international development system. There is a obvious overlap on the ground in the day-to-day business of the World Bank and that of the regional development banks. This is a reality which is being fostered by the growing decentralization of the World Bank into regional hubs; in fact, a recent evaluation by the World Bank’s Independent Evaluation Group concluded that “[r]ather than functioning as a global institution, the bank is at risk of evolving into six regional banks”. With the growing financial strength, institutional capacity and dynamism, and the apparently greater legitimacy of regional development banks among their regional members, shareholders might eventually decide that consolidation of the World Bank’s operations with those of the regional development banks, in favor of the latter, is the preferred approach.

There are lots of reasons to think that this drastic step would be difficult to take politically, financially and administratively, and therefore the inertia common to the international governance architecture will also prevail in this case. However, the new World Bank president would be well advised to be prepared for the possibility of a “perfect storm” under which the idea of eviscerating the World Bank could gain some traction,. The more the bank is seen to fade away, as postulated under Option 1 above, the greater is the likelihood that Option 2 would be given serious consideration.

Option 3: “A Different World Bank” = Creating a Stronger Global Institution for the Coming Decades

Despite all the criticism and the decline in its relative role as a development finance institution in recent decades, the World Bank is still one of the strongest and most effective development institutions in a world. According to a recent independent ranking of the principal multilateral and bilateral aid institutions by the Brookings Institution and the Center for Global Development “IDA consistently ranks among the best aid agencies in each dimension of quality”.

A third, radically different option from the first two, would build on this strength and ensure that the world has an institution 10 to 20 years from now which helps the global community and individual countries to respond effectively to the many global challenges which the world will undoubtedly face: continued poverty, hunger, conflict and fragility, major infrastructure and energy needs, education and health challenges, and global warming and environmental challenges. On top of this, global financial crises will likely recur and require institutions like the World Bank to help countries provide safety nets and the structural foundations of long-term growth, as the bank has amply demonstrated since 2008. With this as a broad mandate, how could the World Bank respond under new dynamic?

First, it would change its organizational and operating modalities to take a leaf out of the book of the vertical funds, which have been so successful in tackling major development challenges in a focused and scaled-up manner. This means substantially rebalancing the internal matrix between the regional and country departments on the one hand and the technical departments on the other hand. According to the same evaluation cited above, the World Bank has tipped too far toward short-term country priorities and has failed to adequately reflect the need for long-term, dedicated sectoral engagement. The World Bank needs to fortify its reputation as an institution that can muster the strongest technical expertise, fielding team with broad global experience and with first rate regional and country perspective. This does not imply that the World Bank would abandon its engagement at the country level, but it means that it would systematically support the pursuit of long-term sectoral and sub-sectoral strategies at the country level, linked to regional and global initiatives, and involving private-public partnership to assure that development challenges are addressed at scale and in a sustained manner.

Second, recognizing that all countries have unmet needs for which they need long-term finance and best practice in areas such as infrastructure, energy, climate change and environment, the World Bank could become a truly global development institution by opening up its funding windows to all countries, not just an arbitrarily defined subset of developing countries. This would require substantially revising the current graduation rules and possibly the financial instruments. This would mean that the World Bank becomes the global equivalent of the European Investment Bank (EIB) and of the German Kreditanstalt fuer Wiederaufbau (KfW)—development banks that have successfully supported the infrastructure development of the more advanced countries.

Third, the World Bank would focus its own knowledge management activities and support for research and development in developing countries much more on a search for effective and scalable solutions, linked closely to its operational engagement which would be specifically designed to support the scaling up of tested innovations, along the lines pioneered by the Bill and Melinda Gates Foundation.

Fourth, for those countries with strong project management capacities, the World Bank would dramatically simplify its lending processes, following the example of the EIB. This would make it a much more efficient operational institution, making it a more attractive partner to its borrowing member countries, especially the emerging market economies.

Fifth, the membership of the World Bank would fix some fundamental problems with its financial structure and governance. It would invite the emerging market economies to make significantly larger contributions to its capital base in line with their much-enhanced economic and financial capacities. It would revamp the bank’s voting and voice rules to reflect the changed global economic weights and financial contributions of emerging markets. The bank would also explore, based on the experience of the vertical funds, tapping the resources of non-official partners, such as foundations and the private sector as part of its capital and contribution base. Of course, this would bring with it further significant changes in the governance of the World Bank. And the bank would move swiftly to a transparent selection of its leadership on the basis of merit without reference to nationality.

Conclusion: The New World Bank President Needs to Work with the G-20 Leaders to Chart a Course Forward
 
The new president will have to make a choice between these three options. Undoubtedly, the easiest choice is “business-as-usual”, perhaps embellished with some marginal changes that reflect the perspective and new insights that an outsider will bring. There is no doubt that the forces of institutional and political inertia tend to prevent dramatic change. However, it is also possible that Dr. Kim, with his background in a relatively narrow sectoral area may recognize the need for a more vertical approach in the bank’s organizational and operational model. Therefore, he may be more inclined than others to explore Option 3.

If he pursues Option 3, Dr. Kim will need a lot of help. The best place to look for help might be the G-20 leadership. One could hope that at least some of the leaders of the G-20 understand that Options 1 and 2 are not in the interest of their countries and the international community. Hopefully, they would be willing to push their peers to contemplate some radical changes in the multilateral development architecture. This might involve the setting up of a high-level commission as recently recommended by this author, which would review the future of the World Bank as part of a broader approach to rationalize the multilateral system in the interest of greater efficiency and effectiveness. But in setting up such a commission, the G-20 should state a clear objective, namely that the World Bank, perhaps the strongest existing global development institution, should not be gutted or gradually starved out of existence. Instead, it needs to be remade into a focused, effective and truly global institution. If Dr. Kim embraces this vision and develops actionable ideas for the commission and the G-20 leaders to consider and support, then he may bring the right medicine for an ailing giant.

On June 20, I moderated a conversation on the future of the Department of Veterans Affairs with Secretary Robert McDonald. When he took office almost two years ago, Secretary McDonald inherited an organization in crisis: too many veterans faced shockingly long wait-times before they received care, VA officials had allegedly falsified records, and other allegations of mismanagement abounded.

Photo: Paul Morigi

Since he was sworn into office, Secretary McDonald has led the VA through a period of ambitious reform, anchored by the MyVA program. He and his team have embraced three core strategies that are securing meaningful change. They are important insights for all government leaders, and private sector ones as well.

1. Set bold goals

Secretary McDonald’s vision is for the VA to become the number one customer-service agency in the federal government. But he and his team know that words alone won’t make this happen. They developed twelve breakthrough priorities for 2016 that will directly improve service to veterans. These actionable short-term objectives support the VA’s longer term aim to deliver an exceptional experience for our veterans. By aiming high, and also drafting a concrete roadmap, the VA has put itself on a path to success.

2. Hybridize the best of public and private sectors

To accomplish their ambitious goal, VA leadership is applying the best practices of customer-service businesses around the nation. The Secretary and his colleagues are leveraging the goodwill, resources, and expertise of both the private and public sector. To do that, the VA has brought together diverse groups of business leaders, medical professionals, government executives, and veteran advocates under their umbrella MyVA Advisory Committee. Following the examples set by private sector leaders in service provision and innovation, the VA is developing user-friendly mobile apps for veterans, modernizing its website, and seeking to make hiring practices faster, more competitive, and more efficient. And so that no good idea is left unheard, the VA has created a "shark tank” to capture and enact suggestions and recommendations for improvement from the folks who best understand daily VA operations—VA employees themselves.

3. Data, data, data

The benefits of data-driven decision making in government are well known. As led by Secretary McDonald, the VA has continued to embrace the use of data to inform its policies and improve its performance. Already a leader in the collection and publication of data, the VA has recently taken even greater strides in sharing information between its healthcare delivery agencies. In addition to collecting administrative and health-outcomes information, the VA is gathering data from veterans about what they think . Automated kiosks allow veterans to check in for appointments, and to record their level of satisfaction with the services provided.

The results that the Secretary and his team have achieved speak for themselves:

• 5 million more appointments completed last fiscal year over the previous fiscal year
• 7 million additional hours of care for veterans in the last two years (based on an increase in the clinical workload of 11 percent over the last two years)
• 97 percent of appointments completed within 30 days of the veteran’s preferred date; 86 percent within 7 days; 22 percent the same day
• Average wait times of 5 days for primary care, 6 days for specialty care, and 2 days for mental health are
• 90 percent of veterans say they are satisfied or completely satisfied with when they got their appointment (less than 3 percent said they were dissatisfied or completely dissatisfied).
• The backlog for disability claims—once over 600,000 claims that were more than 125 days old—is down almost 90 percent.

Thanks to Secretary McDonald’s continued commitment to modernization, the VA has made significant progress. Problems, of course, remain at the VA and the Secretary has more work to do to ensure America honors the debt it owes its veterans, but the past two years of reform have moved the Department in the right direction. His strategies are instructive for managers of change everywhere.

Fred Dews and Andrew Kenealy contributed to this post.

Editor's note: This post originally appeared in the New England Journal of Medicine's Perspective online series on April 22, 2015.

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

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

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

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

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

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

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

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

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

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

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

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

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