So we’ve almost reached the end of the year 2015, which could go down in the history of global sustainable development efforts as one of the more significant years, with the trifecta of the approval of the Sustainable Development Goals (SDGs), the agreement on the Addis Agenda on Financing for Development (FfD) and the (shortly to be completed) Paris COP21 Climate Summit. Yet, all will depend on how the agreements with their ambitious targets are implemented on the ground.

Effective implementation will require a theory of change—a way to think about how we are to get from “here” in 2015 to “there” in 2030. The key problem is what has very appropriately been called by some “the missing middle,” i.e., the gap between the top-down global targets on the one hand and the bottom-up development initiatives, projects, and programs that are supported by governments, aid agencies, foundations, and social entrepreneurs.

One way to begin to close this gap is to aim for scaled-up global efforts in specific areas, as is pledged in the Addis Agenda, including efforts to fight global hunger and malnutrition, international tax cooperation and international cooperation to strengthen capacities of municipalities and other local authorities, investments and international coopera­tion to allow all children to complete free, equitable, inclusive and quality early childhood, primary and secondary education, and concessional and non-concessional financing.

Another way is to develop country-specific national targets and plans consistent with the SDG, Addis, and COP21 targets, as is currently being done with the assistance of the United Nations Development Program’s MAPS program. This can provide broad guidance on policy priorities and resource mobilization strategies to be pursued at the national level and can help national and international actors to prioritize their interventions in areas where a country’s needs are greatest.

However, calling for expanded global efforts in particular priority areas and defining national targets and plans is not enough. Individual development actors have to link their specific projects and programs with the national SDG, Addis, and COP21 targets. They systematically have to pursue a scaling-up strategy in their areas of engagement, i.e., to develop and pursue pathways from individual time-bound interventions to impact at a scale in a way that will help achieve the global and national targets. A recent paper I co-authored with Larry Cooley summarizes two complementary approaches of how one might design and implement such scaling-up pathways. The main point, however, is that only the pursuit of such scaling-up pathways constitutes a meaningful theory of change that offers hope for effective implementation of the new global sustainable development targets.

Fortunately, over the last decade, development analysts and agencies have increasingly focused on the question of how to scale up impact of successful development interventions. Leading the charge, the World Bank in 2004, under its president Jim Wolfensohn, organized a high-level international conference in Shanghai in cooperation with the Chinese authorities on the topic of scaling up development impact and published the associated analytical work. However, with changes in the leadership at the World Bank, the initiative passed to others in the mid-2000s, including the Brookings Institution, ExpandNet (a group of academics working with the World Health Organization), Management Systems International (MSI), and Stanford University. They developed analytical frameworks for systematically assessing scalability of development initiatives and innovations, analyzed the experience with more or less successful scaling-up initiatives, including in fragile and conflict-affected states, and established networks that bring together development experts and practitioners to share knowledge.

By now, many international development agencies (including GIZ, JICA, USAID, African Development Bank, IFAD and UNDP), foundations (including the Bill & Melinda Gates Foundation and Rockefeller Foundation) and leading development NGOs (including Heifer International, Save the Children and the World Resources Institute), among others, have focused on how best to scale up development impact, while the OECD recently introduced a prize for the most successful scaling-up development initiatives. The International Fund for Agricultural Development (IFAD) is perhaps the most advanced among the agencies, having developed a systematic operational approach to the innovation-learning-scaling-up cycle. In a collaborative effort with the Brookings Institution, IFAD reviewed its operational practices and experience and then prepared operational design and evaluation guidelines, which can serve as a good example for other development agencies. The World Bank, while yet to develop a systematic institution-wide approach to the scaling-up agenda, is exploring in specific areas how best to pursue scaled-up impact, such as in the areas of mother and child health, social enterprise innovation, and the “science of delivery.”

Now that the international community has agreed on the SDGs and the Addis Agenda, and is closing in on an agreement in Paris on how to respond to climate change, it is the right time to bridge the “missing middle” by linking the sustainable development and climate targets with effective scaling-up methodologies and practices among the development actors. In practical terms, this requires the following steps:

• Developing shared definitions, analytical frameworks, and operational approaches to scaling up among development experts;
• Developing sectoral and sub-sectoral strategies at country level that link short- and medium-term programs and interventions through scaling-up pathways with the longer-term SDG and climate targets;
• Introducing effective operational policies and practices in the development agencies in country strategies, project design, and monitoring and evaluation;
• Developing multi-stakeholder partnerships around key development interventions with the shared goal of pursuing well-identified scaling-up pathways focused on the achievement of the SDGs and climate targets;
• Developing incentive schemes based on the growing experience with “challenge funds” that focus not only on innovation, but also on scaling up, such as the recently established Global Innovation Fund; and
• Further building up expert and institutional networks to share experience and approaches, such as the Community of Practice on Scaling Up, recently set up by MSI and the Results for Development Institute.

Editor's Note: : We’re hosting a conversation on Markaz on the Iranian nuclear talks, debating the merits of a deal, as well as the broader issues at stake for the United States and the region. This piece originally appeared in The Huffington Post.

As we near what may be the endgame of the current negotiations with Iran, I am reminded of the place where President Obama announced the overarching strategy that helped produce this moment: Prague. After stating his readiness to speak to Iran in a Democratic primary debate in 2007, and following that up postelection in 2009 with a series of initial statements directed to the Iranians, the president chose the Czech capital to lay out his vision of dealing with the dangers of nuclear weapons in April 2009. That included emphasizing that Iran would not be permitted to obtain a nuclear weapon on his watch: "Rules must be binding. Violations must be punished. Words must mean something. The world must stand together to prevent the spread of these weapons."

As a result of that 2009 speech, the president's nuclear strategy became known as the Prague Agenda. I had the privilege to travel with President Obama back to Prague in April 2010 to witness the signing of a major accomplishment in another area under the Prague Agenda, namely the New START treaty. By the following year, April 2011, I was in Prague as U.S. ambassador. That year, and in the each year that followed, we held an annual Prague Agenda conference to assess the steps that had been taken and the challenges that lay ahead.

In the years since, there has been steady progress in each of the four main areas the president laid out on that spring day in Prague in 2009. New START was a step forward on his first objective, to reduce the risks posed by existing nuclear weapons. Another goal, preventing nuclear terror by safeguarding materials and improving safety, has since been the subject of a series of successful Nuclear Security Summits in Washington, Seoul, and The Hague.

I saw first-hand the president's personal commitment to a third objective articulated in Prague: to promote the peaceful use of nuclear energy. I was, for example, present in the Oval Office in October 2011 when the president and the Czech prime minister met. President Obama advocated for the use of civil nuclear power as a part of the Czech energy mix (and also to achieve energy independence from Russia). That approach has been replicated in administration policy supporting civil nuclear energy in the United States and around the world.

Now, with the possible Iran deal, progress under the Prague Agenda's final prong is in reach: holding to account a state which had violated its nuclear obligations under international treaties. I am not of the school that believes the president needs to secure an Iran deal to build his legacy. That was never the case; having known him for almost a quarter of a century, since we were law students together, and having worked for him for six years, first in the White House and then as ambassador, I can attest that those kinds of considerations do not enter into critical decisions like this one. Even the president's strongest critics have to admit that legacy is, as a matter of logic, much less of a consideration after the recent breakthroughs on the Affordable Care Act and on Trade Promotion Authority.

Instead, as the comprehensive nature of the Prague Agenda itself suggests, President Obama is pursuing a deal out of principle. He is acting from his conviction that a good agreement with Iran represents another step toward making the U.S., our allies, and the world safe from nuclear terror. It is that ambition that has driven the president's formulation and consistent pursuit of each of the four elements of the Prague Agenda, the obscure aspects just as much as the headline-making ones.

Of course, as the president himself has repeatedly emphasized, the deal must be a good one. That is why I recently joined a bipartisan group of experts convened by the Washington Institute for Near East Policy in signing a statement laying out criteria for what any deal with Iran must at a minimum contain in five core areas: monitoring and verification; possible military dimensions; advanced centrifuges; sanctions relief; and consequences of violations. We also agreed on the importance of complementing any agreement with a strong deterrence policy and a comprehensive regional strategy. I have been encouraged by the warm reception for our statement from all corners, and by the strong tone struck by the American negotiators in Vienna this week. They recognize that willingness to walk away is the surest path to securing a good deal. If such a deal can be struck that meets the criteria in our bipartisan statement, that will be another stride forward under the Prague Agenda — perhaps the biggest yet.

Part III of the 2015 Brown Center Report on American Education

Student engagement refers to the intensity with which students apply themselves to learning in school.  Traits such as motivation, enjoyment, and curiosity—characteristics that have interested researchers for a long time—have been joined recently by new terms such as, “grit,” which now approaches cliché status.  International assessments collect data from students on characteristics related to engagement.  This study looks at data from the Program for International Student Assessment (PISA), an international test given to fifteen-year-olds.  In the U.S., most PISA students are in the fall of their sophomore year.  The high school years are a time when many observers worry that students lose interest in school.

Compared to their peers around the world, how do U.S. students appear on measures of engagement?  Are national indicators of engagement related to achievement?  This analysis concludes that American students are about average in terms of engagement.  Data reveal that several countries noted for their superior ranking on PISA—e.g., Korea, Japan, Finland, Poland, and the Netherlands—score below the U.S. on measures of student engagement.  Thus, the relationship of achievement to student engagement is not clear cut, with some evidence pointing toward a weak positive relationship and other evidence indicating a modest negative relationship. 

Education studies differ in units of analysis.  Some studies report data on individuals, with each student serving as an observation.  Studies of new reading or math programs, for example, usually report an average gain score or effect size representing the impact of the program on the average student.  Others studies report aggregated data, in which test scores or other measurements are averaged to yield a group score. Test scores of schools, districts, states, or countries are constructed like that.  These scores represent the performance of groups, with each group serving as a single observation, but they are really just data from individuals that have been aggregated to the group level.

Aggregated units are particularly useful for policy analysts.  Analysts are interested in how Fairfax County or the state of Virginia or the United States is doing.  Governmental bodies govern those jurisdictions and policymakers craft policy for all of the citizens within the political jurisdiction—not for an individual.  

The analytical unit is especially important when investigating topics like student engagement and their relationships with achievement.  Those relationships are inherently individual, focusing on the interaction of psychological characteristics.  They are also prone to reverse causality, meaning that the direction of cause and effect cannot readily be determined.  Consider self-esteem and academic achievement.  Determining which one is cause and which is effect has been debated for decades.  Students who are good readers enjoy books, feel pretty good about their reading abilities, and spend more time reading than other kids.  The possibility of reverse causality is one reason that beginning statistics students learn an important rule:  correlation is not causation.

Starting with the first international assessments in the 1960s, a curious pattern has emerged. Data on students’ attitudes toward studying school subjects, when examined on a national level, often exhibit the opposite relationship with achievement than one would expect.  The 2006 Brown Center Report (BCR) investigated the phenomenon in a study of “the happiness factor” in learning.^[i]  Test scores of fourth graders in 25 countries and eighth graders in 46 countries were analyzed.  Students in countries with low math scores were more likely to report that they enjoyed math than students in high-scoring countries.  Correlation coefficients for the association of enjoyment and achievement were -0.67 at fourth grade and -0.75 at eighth grade. 

Confidence in math performance was also inversely related to achievement.  Correlation coefficients for national achievement and the percentage of students responding affirmatively to the statement, “I usually do well in mathematics,” were -0.58 among fourth graders and -0.64 among eighth graders.  Nations with the most confident math students tend to perform poorly on math tests; nations with the least confident students do quite well.   

That is odd.  What’s going on?  A comparison of Singapore and the U.S. helps unravel the puzzle.  The data in figure 3-1 are for eighth graders on the 2003 Trends in Mathematics and Science Study (TIMSS).  U.S. students were very confident—84% either agreed a lot or a little (39% + 45%) with the statement that they usually do well in mathematics.  In Singapore, the figure was 64% (46% + 18%).  With a score of 605, however, Singaporean students registered about one full standard deviation (80 points) higher on the TIMSS math test compared to the U.S. score of 504. 

When within-country data are examined, the relationship exists in the expected direction.  In Singapore, highly confident students score 642, approximately 100 points above the least-confident students (551).  In the U.S., the gap between the most- and least-confident students was also about 100 points—but at a much lower level on the TIMSS scale, at 541 and 448.  Note that the least-confident Singaporean eighth grader still outscores the most-confident American, 551 to 541.

The lesson is that the unit of analysis must be considered when examining data on students’ psychological characteristics and their relationship to achievement.  If presented with country-level associations, one should wonder what the within-country associations are.  And vice versa.  Let’s keep that caution in mind as we now turn to data on fifteen-year-olds’ intrinsic motivation and how nations scored on the 2012 PISA.

PISA’s index of intrinsic motivation to learn mathematics comprises responses to four items on the student questionnaire:  1) I enjoy reading about mathematics; 2) I look forward to my mathematics lessons; 3) I do mathematics because I enjoy it; and 4) I am interested in the things I learn in mathematics.  Figure 3-2 shows the percentage of students in OECD countries—thirty of the most economically developed nations in the world—responding that they agree or strongly agree with the statements.  A little less than one-third (30.6%) of students responded favorably to reading about math, 35.5% responded favorably to looking forward to math lessons, 38.2% reported doing math because they enjoy it, and 52.9% said they were interested in the things they learn in math.  A ballpark estimate, then, is that one-third to one-half of students respond affirmatively to the individual components of PISA’s intrinsic motivation index.

Table 3-1 presents national scores on the 2012 index of intrinsic motivation to learn mathematics.  The index is scaled with an average of 0.00 and a standard deviation of 1.00.  Student index scores are averaged to produce a national score.  The scores of 39 nations are reported—29 OECD countries and 10 partner countries.^[ii]  Indonesia appears to have the most intrinsically motivated students in the world (0.80), followed by Thailand (0.77), Mexico (0.67), and Tunisia (0.59).  It is striking that developing countries top the list.  Universal education at the elementary level is only a recent reality in these countries, and they are still struggling to deliver universally accessible high schools, especially in rural areas and especially to girls.  The students who sat for PISA may be an unusually motivated group.  They also may be deeply appreciative of having an opportunity that their parents never had.

The U.S. scores about average (0.08) on the index, statistically about the same as New Zealand, Australia, Ireland, and Canada.  The bottom of the table is extremely interesting.  Among the countries with the least intrinsically motivated kids are some PISA high flyers.  Austria has the least motivated students (-0.35), but that is not statistically significantly different from the score for the Netherlands (-0.33).  What’s surprising is that Korea (-0.20), Finland (-0.22), Japan (-0.23), and Belgium (-0.24) score at the bottom of the intrinsic motivation index even though they historically do quite well on the PISA math test.

Let’s now dig a little deeper into the intrinsic motivation index.  Two components of the index are how students respond to “I do mathematics because I enjoy it” and “I look forward to my mathematics lessons.”  These sentiments are directly related to schooling.  Whether students enjoy math or look forward to math lessons is surely influenced by factors such as teachers and curriculum.  Table 3-2 rank orders PISA countries by the percentage of students who “agree” or “strongly agree” with the questionnaire prompts.  The nations’ 2012 PISA math scores are also tabled.  Indonesia scores at the top of both rankings, with 78.3% enjoying math and 72.3% looking forward to studying the subject.  However, Indonesia’s PISA math score of 375 is more than one full standard deviation below the international mean of 494 (standard deviation of 92).  The tops of the tables are primarily dominated by low-performing countries, but not exclusively so.  Denmark is an average-performing nation that has high rankings on both sentiments.  Liechtenstein, Hong Kong-China, and Switzerland do well on the PISA math test and appear to have contented, positively-oriented students.

Several nations of interest are shaded.  The bar across the middle of the tables, encompassing Australia and Germany, demarcates the median of the two lists, with 19 countries above and 19 below that position.  The United States registers above the median on looking forward to math lessons (45.4%) and a bit below the median on enjoyment (36.6%).  A similar proportion of students in Poland—a country recently celebrated in popular media and in Amanda Ripley’s book, The Smartest Kids in the World,^[iii] for making great strides on PISA tests—enjoy math (36.1%), but only 21.3% of Polish kids look forward to their math lessons, very near the bottom of the list, anchored by Netherlands at 19.8%. 

Korea also appears in Ripley’s book.  It scores poorly on both items.  Only 30.7% of Korean students enjoy math, and less than that, 21.8%, look forward to studying the subject.  Korean education is depicted unflatteringly in Ripley’s book—as an academic pressure cooker lacking joy or purpose—so its standing here is not surprising.  But Finland is another matter.  It is portrayed as laid-back and student-centered, concerned with making students feel relaxed and engaged.  Yet, only 28.8% of Finnish students say that they study mathematics because they enjoy it (among the bottom four countries) and only 24.8% report that they look forward to math lessons (among the bottom seven countries).  Korea, the pressure cooker, and Finland, the laid-back paradise, look about the same on these dimensions.

Another country that is admired for its educational system, Japan, does not fare well on these measures.  Only 30.8% of students in Japan enjoy mathematics, despite the boisterous, enthusiastic classrooms that appear in Elizabeth Green’s recent book, Building a Better Teacher.^[iv]  Japan does better on the percentage of students looking forward to their math lessons (33.7%), but still places far below the U.S.  Green’s book describes classrooms with younger students, but even so, surveys of Japanese fourth and eighth graders’ attitudes toward studying mathematics report results similar to those presented here.  American students say that they enjoy their math classes and studying math more than students in Finland, Japan, and Korea.

It is clear from Table 3-2 that at the national level, enjoying math is not positively related to math achievement.  Nor is looking forward to one’s math lessons.  The correlation coefficients reported in the last row of the table quantify the magnitude of the inverse relationships.  The -0.58 and -0.57 coefficients indicate a moderately negative association, meaning, in plain English, that countries with students who enjoy math or look forward to math lessons tend to score below average on the PISA math test.  And high-scoring nations tend to register below average on these measures of student engagement.  Country-level associations, however, should be augmented with student-level associations that are calculated within each country.

The 2012 PISA volume on student engagement does not present within-country correlation coefficients on intrinsic motivation or its components.  But it does offer within-country correlations of math achievement with three other characteristics relevant to student engagement. Table 3-3 displays statistics for students’ responses to: 1) if they feel like they belong at school; 2) their attitudes toward school, an index composed of four factors;^[v] and 3) whether they had arrived late for school in the two weeks prior to the PISA test. These measures reflect an excellent mix of behaviors and dispositions.

The within-country correlations trend in the direction expected but they are small in magnitude.  Correlation coefficients for math performance and a sense of belonging at school range from -0.02 to 0.18, meaning that the country exhibiting the strongest relationship between achievement and a sense of belonging—Thailand, with a 0.18 correlation coefficient—isn’t registering a strong relationship at all.  The OECD average is 0.08, which is trivial.  The U.S. correlation coefficient, 0.07, is also trivial.  The relationship of achievement with attitudes toward school is slightly stronger (OECD average of 0.11), but is still weak.

Of the three characteristics, arriving late for school shows the strongest correlation, an unsurprising inverse relationship of -0.14 in OECD countries and -0.20 in the U.S.  Students who tend to be tardy also tend to score lower on math tests.  But, again, the magnitude is surprisingly small.  The coefficients are statistically significant because of large sample sizes, but in a real world “would I notice this if it were in my face?” sense, no, the correlation coefficients are suggesting not much of a relationship at all.    

The PISA report presents within-country effect sizes for the intrinsic motivation index, calculating the achievement gains associated with a one unit change in the index.  One of several interesting findings is that intrinsic motivation is more strongly associated with gains at the top of the achievement distribution, among students at the 90^th percentile in math scores, than at the bottom of the distribution, among students at the 10^th percentile. 

The report summarizes the within-country effect sizes with this statement: “On average across OECD countries, a change of one unit in the index of intrinsic motivation to learn mathematics translates into a 19 score-point difference in mathematics performance.”^[vi]  This sentence can be easily misinterpreted.  It means that within each of the participating countries students who differ by one unit on PISA’s 2012 intrinsic motivation index score about 19 points apart on the 2012 math test.  It does not mean that a country that gains one unit on the intrinsic motivation index can expect a 19 point score increase.^[vii]    

Let’s now see what that association looks like at the national level.

PISA first reported national scores on the index of intrinsic motivation to learn mathematics in 2003.  Are gains that countries made on the index associated with gains on PISA’s math test?  Table 3-4 presents a score card on the question, reporting the changes that occurred in thirty-nine nations—in both the index and math scores—from 2003 to 2012.  Seventeen nations made statistically significant gains on the index; fourteen nations had gains that were, in a statistical sense, indistinguishable from zero—labeled “no change” in the table; and eight nations experienced statistically significant declines in index scores. 

The U.S. scored 0.00 in 2003 and 0.08 in 2012, notching a gain of 0.08 on the index (statistically significant).  Its PISA math score declined from 483 to 481, a decline of 2 scale score points (not statistically significant).

Table 3-4 makes it clear that national changes on PISA’s intrinsic motivation index are not associated with changes in math achievement.  The countries registering gains on the index averaged a decline of 3.7 points on PISA’s math assessment.  The countries that remained about the same on the index had math scores that also remain essentially unchanged (-0.09) And the most striking finding: countries that declined on the index (average of -0.15) actually gained an average of 10.3 points on the PISA math scale.  Intrinsic motivation went down; math scores went up.  The correlation coefficient for the relationship over all, not shown in the table, is -0.30.

The analysis above investigated student engagement.  International data from the 2012 PISA were examined on several dimensions of student engagement, focusing on a measure that PISA has employed since 2003, the index of intrinsic motivation to learn mathematics.  The U.S. scored near the middle of the distribution on the 2012 index.  PISA analysts calculated that, on average, a one unit change in the index was associated with a 19 point gain on the PISA math test.  That is the average of within-country calculations, using student-level data that measure the association of intrinsic motivation with PISA score.  It represents an effect size of about 0.20—a positive effect, but one that is generally considered small in magnitude.^[viii]

The unit of analysis matters.  Between-country associations often differ from within-country associations.  The current study used a difference in difference approach that calculated the correlation coefficient for two variables at the national level: the change in intrinsic motivation index from 2003-2012 and change in PISA score for the same time period.  That analysis produced a correlation coefficient of -0.30, a negative relationship that is also generally considered small in magnitude.

Neither approach can justify causal claims nor address the possibility of reverse causality occurring—the possibility that high math achievement boosts intrinsic motivation to learn math, rather than, or even in addition to, high levels of motivation leading to greater learning.  Poor math achievement may cause intrinsic motivation to fall.  Taken together, the analyses lead to the conclusion that PISA provides, at best, weak evidence that raising student motivation is associated with achievement gains.  Boosting motivation may even produce declines in achievement.

Here’s the bottom line for what PISA data recommends to policymakers: Programs designed to boost student engagement—perhaps a worthy pursuit even if unrelated to achievement—should be evaluated for their effects in small scale experiments before being adopted broadly.  The international evidence does not justify wide-scale concern over current levels of student engagement in the U.S. or support the hypothesis that boosting student engagement would raise student performance nationally.

Let’s conclude by considering the advantages that national-level, difference in difference analyses provide that student-level analyses may overlook.

1. They depict policy interventions more accurately.  Policies are actions of a political unit affecting all of its members.  They do not simply affect the relationship of two characteristics within an individual’s psychology. Policymakers who ask the question, “What happens when a country boosts student engagement?” are asking about a country-level phenomenon.

2.  Direction of causality can run differently at the individual and group levels.  For example, we know that enjoying a school subject and achievement on tests of that subject are positively correlated at the individual level.  But they are not always correlated—and can in fact be negatively correlated—at the group level. 

3.  By using multiple years of panel data and calculating change over time, a difference in difference analysis controls for unobserved variable bias by “baking into the cake” those unobserved variables at the baseline.  The unobserved variables are assumed to remain stable over the time period of the analysis.  For the cultural factors that many analysts suspect influence between-nation test score differences, stability may be a safe assumption.  Difference in difference, then, would be superior to cross-sectional analyses in controlling for cultural influences that are omitted from other models.

4.  Testing artifacts from a cultural source can also be dampened.  Characteristics such as enjoyment are culturally defined, and the language employed to describe them is also culturally bounded.  Consider two of the questionnaire items examined above: whether kids “enjoy” math and how much they “look forward” to math lessons.  Cultural differences in responding to these prompts will be reflected in between-country averages at the baseline, and any subsequent changes will reflect fluctuations net of those initial differences.

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Health reform (aka Obamacare) is entering a new stage. The recent announcement by United Health Care that it will stop selling insurance to individuals and families through most health insurance exchanges marks the transition. In the next stage, federal and state policy makers must decide how to use broad regulatory powers they have under the Affordable Care Act (ACA) to stabilize, expand, and diversify risk pools, improve local market competition, encourage insurers to compete on product quality rather than premium alone, and promote effective risk management. In addition, insurance companies must master rate setting, plan design, and network management and effectively manage the health risk of their enrollees in order to stay profitable, and consumers must learn how to choose and use the best plan for their circumstances.

Six months ago, United Health Care (UHC) announced that it was thinking about pulling out of the ACA exchanges. Now, they are pulling out of all but a “handful” of marketplaces. UHC is the largest private vendor of health insurance in the nation. Nonetheless, the impact on people who buy insurance through the ACA exchanges will be modest, according to careful analyses from the Kaiser Family Foundation and the Urban Institute. The effect is modest for three reasons. One is that in some states UHC focuses on group insurance, not on insurance sold to individuals, where they are not always a major presence. Secondly, premiums of UHC products in individual markets are relatively high. Third, in most states and counties ACA purchasers will still have a choice of two or more other options. In addition, UHC’s departure may coincide with or actually cause the entry of other insurers, as seems to be happening in Iowa.

The announcement by UHC is noteworthy, however. It signals the beginning for ACA exchanges of a new stage in their development, with challenges and opportunities different from and in many ways more important than those they faced during the first three years of operation, when the challenge was just to get up and running. From the time when HealthCare.Gov and the various state exchanges opened their doors until now, administrators grappled non-stop with administrative challenges—how to enroll people, helping them make an informed choice among insurance offerings, computing the right amount of assistance each individual or family should receive, modifying plans when income or family circumstances change, and performing various ‘back office’ tasks such as transferring data to and from insurance companies. The chaotic first weeks after the exchanges opened on October 1, 2013 have been well documented, not least by critics of the ACA. Less well known are the countless behind-the-scenes crises, patches, and work-arounds that harried exchange administrators used for years afterwards to keep the exchanges open and functioning.

The ACA forced not just exchange administrators but also insurers to cope with a new system and with new enrollees. Many new exchange customers were uninsured prior to signing up for marketplace coverage. Insurers had little or no information on what their use of health care would be. That meant that insurers could not be sure where to set premiums or how aggressively to try to control costs, for example by limiting networks of physicians and hospitals enrollees could use. Some did the job well or got lucky. Some didn’t. United seems to have fallen in the second category. United could have stayed in the 30 or so state markets they are leaving and tried to figure out ways to compete more effectively, but since their marketplace premiums were often not competitive and most of their business was with large groups, management decided to focus on that highly profitable segment of the insurance market. Some insurers, are seeking sizeable premium increases for insurance year 2017, in part because of unexpectedly high usage of health care by new exchange enrollees.

United is not alone in having a rough time in the exchanges. So did most of the cooperative plans that were set up under the ACA. Of the 23 cooperative plans that were established, more than half have gone out of business and more may follow. These developments do not signal the end of the ACA or even indicate a crisis. They do mark the end of an initial period when exchanges were learning how best to cope with clerical challenges posed by a quite complicated law and when insurance companies were breaking into new markets. In the next phase of ACA implementation, federal and state policy makers will face different challenges: how to stabilize, expand, and diversify marketplace risk pools, promote local market competition, and encourage insurers to compete on product quality rather than premium alone. Insurance company executives will have to figure out how to master rate setting, plan design, and network management and manage risk for customers with different characteristics than those to which they have become accustomed.

Achieving these goals will require state and federal authorities to go beyond the core implementation decisions that have absorbed most of their attention to date and exercise powers the ACA gives them. For example, section 1332 of the ACA authorizes states to apply for waivers starting in 2017 under which they can seek to achieve the goals of the 2010 law in ways different from those specified in the original legislation. Along quite different lines, efforts are already underway in many state-based marketplaces, such as the District of Columbia, to expand and diversify the individual market risk pool by expanding marketing efforts to enroll new consumers, especially young adults. Minnesota’s Health Care Task Force recently recommended options to stabilize marketplace premiums, including reinsurance, maximum limits on the excess capital reserves or surpluses of health plans, and the merger of individual and small group markets, as Massachusetts and Vermont have done.

In normal markets, prices must cover costs, and while some companies prosper, some do not. In that respect, ACA markets are quite normal. Some regional and national insurers, along with a number of new entrants, have experienced losses in their marketplace business in 2016. One reason seems to be that insurers priced their plans aggressively in 2014 and 2015 to gain customers and then held steady in 2016. Now, many are proposing significant premium hikes for 2017.

Others, like United, are withdrawing from some states. ACA exchange administrators and state insurance officials must now take steps to encourage continued or new insurer participation, including by new entrants such as Medicaid managed care organizations (MCOs). For example, in New Mexico, where in 2016 Blue Cross Blue Shield withdrew from the state exchange, state officials now need to work with that insurer to ensure a smooth transition as it re-enters the New Mexico marketplace and to encourage other insurers to join it. In addition, state insurance regulators can use their rate review authority to benefit enrollees by promoting fair and competitive pricing among marketplace insurers. During the rate review process, which sometimes evolves into a bargaining process, insurance regulators often have the ability to put downward pressure on rates, although they must be careful to avoid the risk of underpricing of marketplace plans which could compromise the financial viability of insurers and cause them to withdraw from the market. Exchanges have an important role in the affordability of marketplace plans too. For example ACA marketplace officials in the District of Columbia and Connecticut work closely with state regulators during the rate review process in an effort to keep rates affordable and adequate to assure insurers a fair rate of return.

Several studies now indicate that in selecting among health insurance plans people tend to give disproportionate weight to premium price, and insufficient attention to other cost provisions—deductibles and cost sharing—and to quality of service and care. A core objective of the ACA is to encourage insurance customers to evaluate plans comprehensively. This objective will be hard to achieve, as health insurance is perhaps the most complicated product most people buy. But it will be next to impossible unless customers have tools that help them take account of the cost implications of all plan features and report accurately and understandably on plan quality and service. HealthCare.gov and state-based marketplaces, to varying degrees, are already offering consumers access to a number of decision support tools, such as total cost calculators, integrated provider directories, and formulary look-ups, along with tools that indicate provider network size. These should be refined over time. In addition, efforts are now underway at the federal and state level to provide more data to consumers so that they can make quality-driven plan choices. In 2018, the marketplaces will be required to display federally developed quality ratings and enrollee satisfaction information. The District of Columbia is examining the possibility of adding additional measures. California has proposed that starting in 2018 plans may only contract with providers and hospitals that have met state-specified metrics of quality care and promote safety of enrollees at a reasonable price. Such efforts will proliferate, even if not all succeed.

Beyond regulatory efforts noted above, insurance companies themselves have a critical role to play in contributing to the continued success of the ACA. As insurers come to understand the risk profiles of marketplace enrollees, they will be better able to set rates, design plans, and manage networks and thereby stay profitable. In addition, insurers are best positioned to maintain the stability of their individual market risk pools by developing and financing marketing plans to increase the volume and diversity of their exchange enrollments. It is important, in addition, that insurers, such as UHC, stop creaming off good risks from the ACA marketplaces by marketing limited coverage insurance products, such as dread disease policies and short term plans. If they do not do so voluntarily, state insurance regulators and the exchanges should join in stopping them from doing so.

Most of the attention paid to the ACA to date has focused on efforts to extend health coverage to the previously uninsured and to the administrative stumbles associated with that effort. While insurance coverage will broaden further, the period of rapid growth in coverage is at an end. And while administrative challenges remain, the basics are now in place. Now, the exchanges face the hard work of promoting vigorous and sustainable competition among insurers and of providing their customers with information so that insurers compete on what matters: cost, service, and quality of health care.

Editor's note: This piece originally appeared in Real Clear Markets. Kevin Lucia and Justin Giovannelli contributed to this article with generous support from The Commonwealth Fund.

SUMMARY:
With the U.S. poverty rate stuck at around 15 percent for years, it’s clear that something needs to change, and candidates need to focus on three pillars of economic advancement-- education, work, family -- to increase economic mobility, according to Brookings Senior Fellow Isabel Sawhill and Senior Research Assistant Edward Rodrigue.

“Economic success requires people’s initiative, but it also requires us, as a society, to untangle the web of disadvantages that make following the sequence difficult for some Americans. There are no silver bullets. Government cannot do this alone. But government has a role to play in motivating individuals and facilitating their climb up the economic ladder,” they write.

The pillar of work is the most urgent, they assert, with every candidate needing to have concrete jobs proposals. Closing the jobs gap (the difference in work rates between lower and higher income households) has a huge effect on the number of people in poverty, even if the new workers hold low-wage jobs. Work connects people to mainstream institutions, helps them learn new skills, provides structure to their lives, and provides a sense of self-sufficiency and self-respect, while at the aggregate level, it is one of the most important engines of economic growth. Specifically, the authors advocate for making work pay (EITC), a second-earner deduction, childcare assistance and paid leave, and transitional job programs. On the education front, they suggest investment in children at all stages of life: home visiting, early childhood education, new efforts in the primary grades, new kinds of high schools, and fresh policies aimed at helping students from poor families attend and graduate from post-secondary institutions. And for the third prong, stable families, Sawhill and Rodrique suggest changing social norms around the importance of responsible, two-person parenthood, as well as making the most effective forms of birth control (IUDs and implants) more widely available at no cost to women.

“Many of our proposals would not only improve the life prospects of less advantaged children; they would pay for themselves in higher taxes and less social spending. The candidates may have their own blend of responses, but we need to hear less rhetoric and more substantive proposals from all of them,” they conclude.

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In their recent blog for Social Mobility Memos, Brad Wilcox, Robert Lerman, and Joseph Price make a convincing case that a stable family structure is an important factor in increased social mobility, higher economic growth, and less poverty over time.

The interesting question is: what lies behind this relationship? Why is a rise (or a smaller decline) in the proportion of married families associated, for example, with higher growth in average family incomes or a decline in poverty? The authors suggest a number of reasons, including the positive effects of marriage for children, less crime, men’s engagement in work, and income pooling. Of these, however, income pooling is by far the most important. Individual earnings have increased very little, if at all, over the past three or four decades, so the only way for families to get ahead was to add a second earner to the household. This is only possible within marriage or some other type of income pooling arrangement like cohabitation. Marriage here is the means: income pooling is the end.

How do we encourage more people to share incomes and expenses? There are no easy answers. Wilcox and his co-authors favor reducing marriage penalties in tax and benefit programs, expanding training and apprenticeship programs, limiting divorces in cases where reconciliation is still possible, and civic efforts to convince young people to follow what I and others have called the “success sequence.” All of these ideas are fine in principle. The question is how much difference they can make in practice. Previous efforts have had at best modest results, as a number of articles in the recent issue of the Brookings-Princeton journal The Future of Children point out.      

Our success sequence, which Wilcox wants to use as the basis for a pro-marriage civic campaign, requires teens and young adults to complete their education, get established in a job, and to delay childbearing until after they are married. The message is the right one.

The problem is that many young adults are having children before marriage. Why? Early marriage is not compatible, in their view, with the need for extended education and training. They also want to spend longer finding the best life partner. These are good reasons to delay marriage. But pregnancies and births still occur, with or without marriage. For better or worse, our culture now tolerates, and often glamorizes, multiple relationships, including premarital sex and unwed parenting. This makes bringing back the success sequence difficult.

Our best bet is to help teens and young adults avoid having a child until they have completed their education, found a steady job, and most importantly, a stable partner with whom they want to raise children, and with whom they can pool their income. In many cases this means marriage; but not in all. The bottom line: teens and young adults need more access and better education and counselling on birth control, especially little-used but highly effective forms as the IUD and the implant. Contraception, not marriage, is where we should be focusing our attention.

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.