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.

The U.S. military will carry out a major modernization of its strategic nuclear forces in the 2020s.

It will cover all three legs of the strategic triad.

Much of the planned program makes sense. The long-range standoff (LRSO) — a new nuclear-armed cruise missile to outfit strategic bombers — does not.

The primary reason for the modernization program is that many US strategic weapons systems are aging out, and American policy is that, as long as there are nuclear weapons, the United States will maintain a safe, secure and robust nuclear deterrent.

The Ohio-class ballistic missile submarines will begin to hit the end of their service life in the late 2020s, and the Navy will need new submarines. Submarines and submarine-launched ballistic missiles (SLBMs) make up the most survivable leg of the triad, and they carry the bulk of deployed US strategic warheads.

The service life of the Minuteman III intercontinental ballistic missile (ICBM) runs out in 2030. The Air Force seeks a replacement ICBM. At a minimum, keeping an ICBM leg of the triad would require another life extension program for existing Minuteman III missiles.

As for the air-breathing leg of the triad, the Air Force wants to procure 80 to 100 B-21 bombers. Plans are shrouded in secrecy but reportedly will incorporate stealth features and advanced electronic warfare capabilities to allow the aircraft to penetrate contested air space. The Air Force is also modernizing the B61 nuclear gravity bomb for use on strategic bombers.

It is not clear why the United States will need to replace 400 deployed ICBMs on a one-for-one basis, particularly as the Air Force several years ago was prepared to go down to 300. A force of 200-300 ICBMs would suffice and result in significant cost savings. Likewise, one can challenge the requirement for 12 new ballistic missile submarines, as opposed to nine or 10.

The biggest question, however, arises over the LRSO, with a projected cost of $20 billion to $30 billion. The Air Force originally developed nuclear-armed air-launched cruise missiles (ALCMs) in the 1970s because the B-52 — then the mainstay of the strategic bomber fleet — presented a big target for adversary radars. That would make it hard for the aircraft to penetrate air defenses. A B-52 armed with ALCMs could remain outside of radar range and release its cruise missiles.

The B-2, with its stealth features, was designed to restore a penetrating capability. The Air Force plans to use stealth and electronic warfare capabilities to give the B-21 a penetrating capability as well. If these bombers can defeat and penetrate air defenses, that makes the LRSO redundant. (Moreover, unlike in the 1970s, the Air Force today has very capable long-range conventionally armed cruise missiles that provide a standoff capability for bombers.)

If, on the other hand, the stealth of the B-21 will be compromised in the not-too-distant future, then one has to question the wisdom of spending $60 billion to $80 billion — and perhaps more — to procure the B-21. If we believe the B-21 would soon encounter problems penetrating air defenses, scrap that program. Buy instead modified Boeing 767s, a variant of which will serve as the Air Force’s new aerial tanker, and arm them with the LRSO.

The Air Force’s evident attachment to the B-21 suggests, however, that it believes that the aircraft will be able to defeat adversary air defenses for some time to come. That means that the LRSO would add little capability to the US strategic force mix.

If one were to argue for the redundant capability provided by the LRSO, the number of new ALCMs that the Pentagon proposes to purchase — 1,000 to 1,100 — is difficult to understand. Even allowing for extra cruise missiles for test purposes, the number seems excessively high.

In its 2010 annual report to Congress on implementation of the Strategic Offensive Arms Reduction Treaty (SORT), the State Department advised that, as of Dec. 31, 2009, the United States had 1,968 operationally deployed strategic nuclear warheads. That figure captured the actual number of nuclear warheads atop SLBMs and ICBMs plus the number of nuclear bombs and ALCMs at air bases for use by bombers.

On June 1, 2011, a State Department fact sheet showed the number of deployed US strategic warheads as 1,800 as of Feb. 5, 2011, when the New Strategic Arms Reduction Treaty (New START) went into force. A Dec. 1, 2011, fact sheet provided a more detailed breakdown of US strategic forces. It stated that, as of Sept. 1, 2011, the United States had 1,790 deployed strategic warheads and 125 deployed strategic bombers. Like SORT, New START counts each warhead on a deployed ballistic missile as a deployed warhead. But New START counts bomber weapons differently from SORT. New START attributes each deployed bomber as one warhead, regardless of the number that it can carry or the number of weapons that may be at bomber bases.

The 125 deployed bombers on Sept. 1, 2011, would have counted as 125 under New START’s deployed strategic warhead total. Reducing 1,790 by 125 yields 1,665 — the number of deployed warheads then on US SLBMs and ICBMs.

Comparing the SORT and New START numbers is a bit of an apples-and-oranges comparison, but it gives some idea of the number of bomber weapons at US strategic bomber bases. Unless there was a dramatic increase in the number of warheads on ICBMs and SLBMs between the end of 2009 and September 2011 — and there is no reason to think that there was — comparing SORT’s 1,968 figure (end of 2009) to the 1,665 deployed warheads on ICBMs and SLBMs (under New START counting rules in September 2011) suggests some 300 nuclear bombs and ALCMs were at bomber bases. The B-2s would have been armed with bombs, which indicates a maximum of 200-250 ALCMs. The Federation of American Scientists (FAS) also estimates that there are about 300 nuclear weapons at strategic bomber bases, of which 200 are nuclear-armed ALCMs. FAS believes an additional 375 ALCM airframes are held in reserve.

This comparison raises the question: Why would 1,000-1,100 ALCM airframes be needed to support a couple of hundred deployed ALCMs?

The United States should sensibly modernize its strategic deterrent, particularly in a time of tight defense budgets. The case for the LRSO is demonstrably weak, especially for the planned size of the program. The LRSO should be shelved.

This piece was originally published in Defense News.

Editors’ Note: Presumptive Republican presidential nominee Donald Trump has proposed, in various forms and iterations, banning Muslims from entering the United States “until we figure out what’s going on,” in his words. Shadi Hamid responds to this proposal below, in an excerpt from a longer piece in The Atlantic in which Uri Friedman surveys various experts on the issue.

If Donald Trump is really interested in understanding the roots of anti-Americanism, there’s a solution: to read the hundreds of books and articles written on why, exactly, “Muslims” might not be particularly enthused about American policy in the Middle East (there’s little evidence to suggest that large numbers of Muslims have any particular antipathy toward Americans as people).

But it’s possible that Trump is just being imprecise. Perhaps what he really wants to say is not that Muslims “hate” Americans, but rather that they may be ambivalent about or even opposed to certain liberal values that are associated with being American. Obviously, it is impossible to generalize about an entire religious group, but polling does suggest that majorities in Arab countries like Egypt and Jordan, as well as non-Arab countries like Indonesia and Malaysia, aren’t quite classical liberals when it comes to issues like apostasy, religiously derived criminal punishments, gender equality, or the relevance of religious law in public life more generally.

If this happens to be Trump’s argument, it would be ironic, since Trump himself cannot be considered a liberal in the classical sense. In fact, he fits the definition of an “illiberal democrat” quite well, as I argued in a recent essay here in The Atlantic. That said, I have to admit that I’m concerned about anti-Muslim bigots misconstruing my own arguments around “Islamic exceptionalism”—that Islam has been and will continue to be resistant to secularization—after the attacks in Orlando. It’s undoubtedly true that large numbers of Muslims in both the West and the Middle East consider homosexual activity to be religiously unlawful, or haram, but let us be careful in drawing a link between such illiberalism (which many Christian evangelicals and Republican politicians share) and the desire to kill. That’s not the way radicalization works. We would never argue, for instance, that Senators Ted Cruz or Marco Rubio are “at risk” individuals who may, if we don’t keep a close eye on them, commit mass murder against gay Americans.

In any case, conservative Muslims, orthodox Jews, Christian evangelicals (or for that matter Trump supporters residing in Poland who want to emigrate to the U.S. if Trump wins) have the right to be “illiberal” as long as they express their illiberalism through legal, democratic means. These are rights that are protected by the American constitution, enshrined in the Bill of Rights.

Perhaps Trump is thinking specifically about violence perpetrated by Muslims, as he suggested in comments after the Orlando attacks. The interesting thing though—and something that is rarely acknowledged by U.S. politicians—is that the preponderance of Middle Eastern violence in recent decades has been perpetrated not by Islamists but by secular autocrats against Islamists, in the name of national security. These, as it happens, are the very strongmen that Trump seems to have such a soft spot for.

Ultimately, Trump cannot, through the force of arms or his genuinely frightening anti-Muslim rhetoric, compel the many conservative Muslims in the Middle East to be something they’re not, or would rather not be. To suggest that Muslims need to be secular or irreligious (by Trump’s own arbitrary standards) is dangerous. The message there is one that ISIS would find appealing for its own divisive purposes: that an increasingly populist and bigoted West has no interest in respecting or accommodating Islam’s role in public life, even when expressed legally and peacefully. The sad fact of the matter, though, is simple enough: Trump has less respect for the American constitution than the vast majority of American Muslims, many of whom, like me, are the children of immigrants. In Trump’s America, it so happens, my parents would have been banned from ever entering in the first place.

A central function of the United States Congress is oversight of the executive branch. Congressional oversight, as exercised from the beginning of the nation, is an essential tool in making the separation of powers real by empowering Congress to check the executive. In recent years, however, as polarization has reached paralyzing levels, Congress has largely gotten out of the business of routine and prospective “police-patrol” oversight.  In the absence of the will and the capacity to do prospective oversight, Congress is at risk of losing its power to the executive branch and thus failing one of its most important constitutional roles.

This paper assesses whether or not anything can be done to get Congress back into the oversight business. Specifically, author Elaine Kamarck examines the following question: Assuming that future Congresses develop the political will to conduct oversight, do they have the capacity to do oversight of a large, modern, and complex executive branch?

As Kamarck illustrates, mismatched resources may make it difficult for Congress to resume its oversight function. The modern federal government is a complex and enormous enterprise. But as the executive branch has grown considerably over the past decades, Congress has adopted budget cuts that make the legislative branch less and less capable of undertaking the kinds of systemic oversight that can solve or prevent problems. Congress employs a mere 17,272 professional staff to oversee an executive branch consisting of 4.2 million civil servants and uniformed military. 

“The existing infrastructure that is supposed to help Congress be on top of the executive branch has fallen prey to a mindless dumbing down of Congress,” Kamarck states. She details the five entities that are meant to support Congress in its oversight role: committee staff, the Congressional Research Service, the Government Accountability Office, the Congressional Budget Office, and the Inspectors General, all of which are understaffed and under-budgeted. Kamarck recommends the first thing Congress should do to fix its oversight problem is to properly staff the agencies it already has and to stop nickel and diming and degrading its own capacity.

Furthermore, Kamarck calls for a “Congressional Oversight Office,” a body charged with evaluating governmental performance before a crisis arises. This office should be staffed by implementation professionals who can gather the signals from all the other oversight organizations annually and in sync with the budget cycle.

“Congress needs to get back into the business of productive executive branch oversight,” concludes Kamarck. A Congressional Oversight Office is certainly a step in that direction.

Downloads

• Download the paper

Financial advisors offer their clients many advantages, such as setting reasonable savings goals, avoiding fraudulent investments and mistakes like buying high and selling low, and determining the right level of risk for a particular household. However, these same advisors are often incentivized to choose funds that increase their own financial rewards, and the nature and amount of the fees received by advisors may not be transparent to their clients, and small-scale savers may not be able to access affordable advice at all.  What is in the best interest of an individual may not be in the best interest of his or her financial advisor.

To combat this problem, the Department of Labor (DoL) recently proposed a regulation designed to increase consumer protection by treating some investment advisors as fiduciaries under ERISA and the 1986 Internal Revenue Code.  The proposed conflict of interest rule is an important step in the right direction to increasing consumer protections.  It addresses evidence from a February 2015 report by the Council of Economic Advisers suggesting that consumers often receive poor recommendations from their financial advisors and that as a result their investment returns on IRAs are about 1 percentage point lower each year.   Naturally, the proposal is not without its controversies and it has already attracted at least 775 public comments, including one from us .

For us, the DoL’s proposed rule is a significant step in the right direction towards increased consumer protection and retirement security.  It is important to make sure that retirement advisors face the right incentives and place customer interests first.  It is also important make sure savers can access good advice so they can make sound decisions and avoid costly mistakes.  However, some thoughtful revisions are needed to ensure the rule offers a net benefit. 

If the rule causes advisors’ compliance costs to rise, they may abandon clients with small-scale savings, since these clients will no longer be profitable for them.  If these small-scale savers are crowded out of the financial advice market, we might see the retirement savings gap widen.  Therefore we encourage the DoL to consider ways to minimize or manage these costs, perhaps by incentivizing advisors to continue guiding these types of clients.  We also worry that the proposed rule does not adequately clarify the difference between education and advice, and encourage the DoL to close any potential loopholes by standardizing the general educational information that advisors can share without triggering fiduciary responsibility (which DoL is trying to do).  Finally, the proposed rule could encourage some advisors to become excessively risk averse in an overzealous attempt to avoid litigation or other negative consequences.  Extreme risk aversion could decrease market returns for investors and the ‘value-add’ of professional advisors, so we suggest the DoL think carefully about discouraging conflicted advice without also discouraging healthy risk.

The proposed rule addresses an important problem, but in its current form it may open the door to some undesirable or problematic outcomes.  We explore these issues in further detail in our recent paper.

Introduction

I would like to thank the Department for giving me the opportunity to testify on this important issue. The document I submitted to you is more general than most of the comments you have received, talking about the issues facing retirement savers and policymakers, rather than engaging in a point-by-point discussion of the detailed DOL proposal¹.

Issues around Retirement Saving

1. Most workers in the bottom third of the income distribution will rely on Social Security to support them in retirement and will save little. Hence it is vital that we support Social Security in roughly its present form and make sure it remains funded, either by raising revenues or by scaling back benefits for higher income retirees, or both.

2. Those in the middle and upper middle income levels must now rely on 401k and IRA funds to provide income support in retirement. Many and perhaps most households lack a good understanding of the amount they need to save and how to allocate their savings. This is true even of many savers with high levels of education and capabilities.

3. The most important mistakes made are: not saving enough; withdrawing savings prior to retirement; taking Social Security benefits too early² ; not managing tax liabilities effectively; and failing to adequately manage risk in investment choices. This last category includes those who are too risk averse and choose low-return investments as well as those that overestimate their own ability to pick stocks and time market movements. These points are discussed in the paper I submitted to DoL in July. They indicate that retirement savers can benefit substantially from good advice.

4. The market for investment advice is one where there is asymmetric information and such markets are prone to inefficiency. It is very hard to get incentives correctly aligned. Professional standards are often used as a way of dealing with such markets but these are only partially successful. Advisers may be compensated through fees paid by the investment funds they recommend, either a load fee or a wrap fee. This arrangement can create an incentive for advisers to recommend high fee plans.

5. At the same time, advisers who encourage increased saving, help savers select products with good returns and adequate diversification, and follow a strategy of holding assets until retirement provide benefits to their clients.

Implications for the DoL’s proposed conflicted interest rule

1. Disclosure. There should be a standardized and simple disclosure form provided to all households receiving investment advice, detailing the fees they will be paying based on the choices they make. Different investment choices offered to clients should be accompanied by a statement describing how the fees received by the adviser would be impacted by the alternative recommendations made to the client.

2. Implications for small-scale savers. The proposed rule will bring with it increased compliance costs. These costs, combined with a reluctance to assume more risk and a fear of litigation, may make some advisers less likely to offer retirement advice to households with modest savings. These households are the ones most in need of direction and education, but because their accounts will not turn profits for advisors, they may be abandoned. According to the Employee Benefits Security Administration (EBSA), the proposed rule will save families with IRAs more than $40 billion over the next decade. However, this benefit must be weighed against the attendant costs of implementing the rule. It is possible that the rule will leave low- and medium-income households without professional guidance, further widening the retirement savings gap. The DoL should consider ways to minimize or manage these costs. Options include incentivizing advisors to continue guiding small-scale savers, perhaps through the tax code, and promoting increased financial literacy training for households with modest savings. Streamlining and simplifying the rules would also help.

3. Need for Research on Online Solutions. The Administration has argued that online advice may be the solution for these savers, and for some fraction of this group that may be a good alternative. Relying on online sites to solve the problem seems a stretch, however. Maybe at some time in the future that will be a viable option but at present there are many people, especially in the older generation, who lack sufficient knowledge and experience to rely on web solutions. The web offers dangers as well as solutions, with the potential for sub-optimal or fraudulent advice. I urge the DoL to commission independent research to determine how well a typical saver does when looking for investment advice online. Do they receive good advice? Do they act on that advice? What classes of savers do well or badly with online advice? Can web advice be made safer? To what extent do persons receiving online advice avoid the mistakes described earlier?

4. Pitfalls of MyRA. Another suggestion by the Administration is that small savers use MyRA as a guide to their decisions and this option is low cost and safe, but the returns are very low and will not provide much of a cushion in retirement unless households set aside a much larger share of their income than has been the case historically.

5. Clarifications about education versus advice. The proposed rule distinguished education from advisement. An advisor can share general information on best practices in retirement planning, including making age-appropriate asset allocations and determining the ideal age at which to retire, without triggering fiduciary responsibility. This is certainly a useful distinction. However, some advisors could frame this general information in a way that encourages clients to make decisions that are not in their own best interest. The DoL ought to think carefully about the line between education and advice, and how to discourage advisors from sharing information in a way that leads to future conflicts of interest. One option may be standardizing the general information that may be provided without triggering fiduciary responsibility.

6. Implications for risk management. Under the proposed rule advisors may be reluctant to assume additional risk and worry about litigation. In addition to pushing small-scale savers out of the market, the rule may encourage excessive risk aversion in some advisors. General wisdom suggests that young savers should have relatively high-risk portfolios, de-risking as they age, and ending with a relatively low-risk portfolio at the end of the accumulation period. The proposed rule could cause advisors to discourage clients from taking on risk, even when the risk is generally appropriate and the investor has healthy expectations. Extreme risk aversion could decrease both market returns for investors and the “value-add” of professional advisors. The DoL should think carefully about how it can discourage conflicted advice without encouraging overzealous risk reductions.

The proposed rule is an important effort to increase consumer protection and retirement security. However, in its current form, it may open the door to some undesirable or problematic outcomes. With some thoughtful revisions, I believe the rule can provide a net benefit to the country.

^{1. Baily’s work has been assisted by Sarah E. Holmes. He is a Senior Fellow at the Brookings Institution and a Director of The Phoenix Companies, but the views expressed are his alone.}

^{2. As you know, postponing Social Security benefits yields an 8 percent real rate of return, far higher than most people earn on their investments. For most of those that can manage to do so, postponing the receipt of benefits is the best decision.}

Downloads

• Download the full testimony

If you’re reading this article, chances are you know people who are still getting married. But it’s getting rarer, especially among the youngest generation and those who are less educated. We used to assume people would marry before having children. But marriage is no longer the norm. Half of all children born to women under 30 are born out of wedlock. The proportion is even higher among those without a college degree.

What’s going on here? Most of today’s young adults don’t feel ready to marry in their early 20s. Many have not completed their educations; others are trying to get established in a career; and many grew up with parents who divorced and are reluctant to make a commitment or take the risks associated with a legally binding tie.

But these young people are still involved in romantic relationships. And yes, they are having sex. Any stigma associated with premarital sex disappeared a long time ago, and with sex freely available, there’s even less reason to bother with tying the knot. The result: a lot of drifting into unplanned pregnancies and births to unmarried women and their partners with the biggest problems now concentrated among those in their 20s rather than in their teens. (The teen birth rate has actually declined since the early 1990s.)

Does all of this matter? In a word, yes.

These trends are not good for the young people involved and they are especially problematic for the many children being born outside marriage. The parents may be living together at the time of the child’s birth but these cohabiting relationships are highly unstable. Most will have split before the child is age 5.

Social scientists who have studied the resulting growth of single-parent families have shown that the children in these families don’t fare as well as children raised in two-parent families. They are four or five times as likely to be poor; they do less well in school; and they are more likely to engage in risky behaviors as adolescents. Taxpayers end up footing the bill for the social assistance that many of these families need.

Is there any way to restore marriage to its formerly privileged position as the best way to raise children? No one knows. The fact that well-educated young adults are still marrying is a positive sign and a reason for hope. On the other hand, the decline in marriage and rise in single parenthood has been dramatic and the economic and cultural transformations behind these trends may be difficult to reverse.

Women are no longer economically dependent on men, jobs have dried up for working-class men, and unwed parenthood is no longer especially stigmatized. The proportion of children raised in single-parent homes has, as a consequence, risen from 5 percent in 1960 to about 30 percent now.

Conservatives have called for the restoration of marriage as the best way to reduce poverty and other social ills. However, they have not figured out how to do this.

The George W. Bush administration funded a series of marriage education programs that failed to move the needle in any significant way. The Clinton administration reformed welfare to require work and thus reduced any incentive welfare might have had in encouraging unwed childbearing. The retreat from marriage has continued despite these efforts. We are stuck with a problem that has no clear governmental solution, although religious and civic organizations can still play a positive role.

But perhaps the issue isn’t just marriage. What may matter even more than marriage is creating stable and committed relationships between two mature adults who want and are ready to be parents before having children. That means reducing the very large fraction of births to young unmarried adults that occur before these young people say they are ready for parenthood.

Among single women under the age of 30, 73 percent of all pregnancies are, according to the woman herself, either unwanted or badly mistimed. Some of these women will go on to have an abortion but 60 percent of all of the babies born to this group are unplanned.

As I argue in my book, “Generation Unbound,” we need to combine new cultural messages about the importance of committed relationships and purposeful childbearing with new ways of helping young adults avoid accidental pregnancies. The good news here is that new forms of long-acting but fully reversible contraception, such as the IUD and the implant, when made available to young women at no cost and with good counseling on their effectiveness and safety, have led to dramatic declines in unplanned pregnancies. Initiatives in the states of Colorado and Iowa, and in St. Louis have shown what can be accomplished on this front.

Would greater access to the most effective forms of birth control move the needle on marriage? Quite possibly. Unencumbered with children from prior relationships and with greater education and earning ability, young women and men would be in a better position to marry. And even if they fail to marry, they will be better parents.

My conclusion: marriage is in trouble and, however desirable, will be difficult to restore. But we can at least ensure that casual relationships outside of marriage don’t produce children before their biological parents are ready to take on one of the most difficult social tasks any of us ever undertakes: raising a child. Accidents happen; a child shouldn’t be one of them.

The issue of paid leave is heating up in 2016. At least two presidential candidates — Democrat Hillary Clinton and Republican Sen. Marco Rubio (Fla.) — have proposed new federal policies. Several states and large cities have begun providing paid leave to workers when they are ill or have to care for a newborn child or other family member.

This forward movement on paid-leave policy makes sense. The United States is the only advanced country without a paid-leave policy. While some private and public employers already provide paid leave to their workers, the workers least likely to get paid leave are low-wage and low-income workers who need it most. They also cannot afford to take unpaid leave, which the federal government mandates for larger companies.

Paid leave is good for the health and development of children; it supports work, enabling employees to remain attached to the labor force when they must take leave; and it can lower costly worker turnover for employers. Given the economic and social benefits it provides and given that the private market will not generate as much as needed, public policies should ensure that such leave is available to all.

But it is important to do so efficiently, so as not to burden employers with high costs that could lead them to substantially lower wages or create fewer jobs.

States and cities that require employers to provide paid sick days mandate just a small number, usually three to seven days. Family or temporary disability leaves that must be longer are usually financed through small increases in payroll taxes paid by workers and employers, rather than by employer mandates or general revenue.

Policy choices could limit costs while expanding benefits. For instance, states should limit eligibility to workers with experience, such as a year, and it might make sense to increase the benefit with years of accrued service to encourage labor force attachment. Some states provide four to six weeks of family leave, though somewhat larger amounts of time may be warranted, especially for the care of newborns, where three months seems reasonable.

Paid leave need not mean full replacement of existing wages. Replacing two-thirds of weekly earnings up to a set limit is reasonable. The caps and partial wage replacement give workers some incentive to limit their use of paid leave without imposing large financial burdens on those who need it most.

While many states and localities have made sensible choices in these areas, some have not. For instance, the D.C. Council has proposed paid-leave legislation for all but federal workers that violates virtually all of these rules. It would require up to 16 weeks of temporary disability leave and up to 16 weeks of paid family leave; almost all workers would be eligible for coverage, without major experience requirements; and the proposed law would require 100 percent replacement of wages up to $1,000 per week, and 50 percent coverage up to $3,000. It would be financed through a progressive payroll tax on employers only, which would increase to 1 percent for higher-paid employees.

Our analysis suggests that this level of leave would be badly underfunded by the proposed tax, perhaps by as much as two-thirds. Economists believe that payroll taxes on employers are mostly paid through lower worker wages, so the higher taxes needed to fully fund such generous leave would burden workers. The costly policy might cause employers to discriminate against women.

The disruptions and burdens of such lengthy leaves could cause employers to hire fewer workers or shift operations elsewhere over time. This is particularly true here, considering that the D.C. Council already has imposed costly burdens on employers, such as high minimum wages (rising to $11.50 per hour this year), paid sick leave (although smaller amounts than now proposed) and restrictions on screening candidates. The minimum wage in Arlington is $7.25 with no other mandates. Employers will be tempted to move operations across the river or to replace workers with technology wherever possible.

Cities, states and the federal government should provide paid sick and family leave for all workers. But it can and should be done in a fiscally responsible manner that does not place undue burdens on the workers themselves or on their employers.

Editor's note: this piece originally appeared in The Washington Post.