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.

INTRODUCTION

In December 2011, the United Nations State of the World’s Volunteering Report was released at the U.N. headquarters in New York along with a General Assembly resolution championing the role of volunteer action in peacebuilding and development. The United Nations Volunteers (UNV) Program report states that:

The contribution of volunteerism to development is particularly striking in the context of sustainable livelihoods and value-based notions of wellbeing. Contrary to common perceptions, the income poor are as likely to volunteer as those who are not poor. In doing so, they realize their assets, which include knowledge, skills and social networks, for the benefit of themselves, their families and their communities…Moreover, volunteering can reduce the social exclusion that is often the result of poverty, marginalization and other forms of inequality…There is mounting evidence that volunteer engagement promotes the civic values and social cohesion which mitigate violent conflict at all stages and that it even fosters reconciliation in post-conflict situations...

The “South Africa Conference on Volunteer Action for Development” convened in Johannesburg in October 2011, and the July 2012 “Africa Conference on Volunteer Action for Peace and Development” co-hosted with the Kenya’s Ministry of East African Community, the United Nations and partners in Nairobi give further evidence to the rise of and potential for volunteer service to impact development and conflict. Indeed, in the aftermath of the 2011 Arab Spring, youth volunteer service and empowerment have emerged as a pivotal idea in deliberations aimed at fostering greater regional cohesion and development.

In “Foresight Africa: Top Priorities for the Continent in 2012,” Mwangi S. Kimenyi and Stephen N. Karingi note that: “One of the most important pillars in determining whether the positive prospects for Africa will be realized is success in regional integration… This year is a crucial one for Africa’s regional integration project and actions by governments, regional organizations and the international community will be critical in determining the course of the continent’s development for many years to come.”

The authors note the expected completion of a tripartite regional free trade agreement by 2014 and the expected boost to intra-African trade, resulting in an expanded market of 26 African countries (representing more than half of the region’s economic output and population). At the same time, the declaration from the “South Africa Conference on Volunteer Action for Development” calls on “Governments of Southern African member states and other stakeholders to incorporate volunteering in their deliberations from Rio +20 and to recognize the transformational power as well as economic and social value of volunteering in achieving national development goals and regional priorities, which can be achieved by facilitating the creation of an enabling environment for volunteering to support, protect and empower volunteers.” This speaks directly to the urgent need to factor the social dimension into the regional integration agenda in the different African subregions.

This paper includes examples of the growth of volunteer service as a form of social capital that enhances cohesion and integration across three regions: southern, western, and eastern Africa. It further highlights civil society best practices and policy recommendations for increased volunteering in efforts to ensure positive peace, health, youth skills, assets and employment outcomes.

The importance of volunteering to development has been noted in recent United Nations consultations on the Rio+20 convening on sustainable development and the post-2015 development framework. As the U.N. reviews its Millennium Development Goals (MDG) process, Africa’s regional service initiatives offer vital lessons and strategies to further achieve the MDGs by December 2015, and to chart the way forward on the post-2015 development framework.

But how does volunteerism and civic service play out in sub-Saharan Africa? What are its institutional and non-institutional expressions? What are the benefits or impacts of volunteerism and civic service in society? Our specific purpose here is to provide evidence of the different manifestations and models of service, impact areas and range of issues in three African regions. In responding to these questions, this analysis incorporates data and observations from southern, western and eastern Africa.

In conclusion, we provide further collective insights and recommendations for the roles of the Africa Union and regional economic communities (RECs), youth, the international community, the private sector and civil society aimed at ensuring that volunteerism delivers on its promise and potential for impact on regional integration, youth development and peace.

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"We are now locked in a rolling filibuster on every issue, which is totally gridlocking the U.S. Senate. That is wrong. It is wrong for America."

Who said that? Democrat Harry Reid, majority leader of the Senate? Guess again. Try former Republican leader Trent Lott, bemoaning the troubled state of the Senate in the late 1990s.

No recent majority leader of either party has been saved the headache of trying to lead a Senate in which minorities can exploit the rules and stymie the chamber. This is not a new problem. Harry Reid may face a particularly unrestrained minority. But generations of Senate leaders from Henry Clay to Bill Frist have felt compelled to seek changes in Senate rules to make the chamber a more governable place.

Some things never change.

Twice this week, the Senate has opened debate with its party leaders engaged in a caustic battle over Reid's plans to seek changes to Senate rules in January.

Read the full piece at CNN.com »

For nearly fifteen hours between Wednesday morning and early Thursday, Senator Chris Murphy (D-CT), along with his Connecticut colleague Senator Richard Blumenthal (D) and Senator Cory Booker (D-NJ), led a filibuster on the floor of the Senate aimed at addressing gun control issues in the aftermath of last weekend’s mass shooting in Orlando. Other than learning that Wednesday is pizza night in the Murphy household, what else should we take away from this Mr. Smith Goes to Washington­-style exercise? Here are three lessons:

1. The real meaning of “I” in “I hold the floor until I yield the floor.”

Anyone who tuned into yesterday’s filibuster joined Senate procedure wonks (and faithful viewers of the West Wing) in the knowledge that a senator who holds the floor can yield to another senator for a question without yielding the floor. Indeed, 38 of Murphy’s 45 Democratic colleagues (as well as two Republicans, Senators Ben Sasse (R-NE) and Pat Toomey (R-PA)), came to the chamber yesterday to ask “questions.” In many cases, these were lengthy speeches—Senator Tammy Baldwin (D-WI), for example, read brief biographies of all 49 Orlando victims—in which the speaker satisfied the question requirement with a conclusion that asked Murphy for his reactions to their statement.

This kind of teamwork on extended speech-making is not unusual. When Senator Ted Cruz (R-TX) took the floor to talk for 21 hours about the Affordable Care Act in 2013, he took questions from nine fellow Republicans (as well as two Democrats). Last May, Senator Rand Paul (R-KY) got an assist from ten colleagues, including seven Democrats, during his filibuster of a bill extending the PATRIOT Act. The depth of Murphy’s bench not only reduced the energy he had to expend speaking, but also helped guarantee that the entire discussion was on-message and focused on the topic at hand; Murphy did not have to resort to reading the phone book to fill the hours.

2. In policy terms, it’s hard to know if the filibuster was a success…

When Murphy left the floor early Thursday morning, it was reported that Senate leaders had agreed to consider two gun control amendments: one that would address the ability of suspected terrorists to purchase guns and a second that would expand background checks for gun purchases. Details of the deal ensuring consideration are still emerging, but it is difficult to know if Murphy’s filibuster caused Senate leaders to agree to hold votes on them. It is possible that, had Democrats simply threatened to object to the motion to proceed to debate on the underlying spending bill, Republican leaders would have been forced to agree to consider the amendments for which Murphy and his allies were pushing. In the contemporary Senate, this is often how obstruction proceeds: without extended speeches and off the floor, with the two sides negotiating behind the scenes.

3. …but the political victory is perhaps more important

As my colleague Sarah Binder and her co-author Steve Smith wrote in their 1997 book on the filibuster, “encouragement from external groups…has given senators an incentive to exploit their procedural rights, sometimes leading them to block legislation with the filibuster or with holds and at other times leading them to use procedural prerogatives to force the Senate to consider issues of importance to parochial, partisan, or national constituencies.” On these grounds, Murphy’s filibuster was unequivocally a success in the eyes of its supporters. As the filibuster neared its end, Murphy reported that his office had received 10,000 phone calls supporting his efforts, and the hashtag #filibuster was trending on Twitter for much of the day. Even if the underlying amendments are not adopted—a real possibility that Murphy acknowledged in one of his final speeches of the evening—the visibility of the exercise is likely to pay political dividends for Democrats in the coming weeks.

The Venezuelan opposition Movement for Democratic Unity (or MUD by its Spanish acronym) won a major victory over pro-government parties in the December 6 legislative elections. Updated official results show 107 seats for the MUD, 55 for the governing party, 3 representing indigenous communities, with 2 still undecided.

This is remarkable considering the extent to which the government manipulated electoral rules and conditions ahead of the elections. There were a number of reported problems on election day, the most serious of which was to keep polling stations open for up to two additional hours so government supporters could scour voter rolls to find eligible voters who had not yet cast ballots and take them to polling stations. The result was a record 74 percent turnout for legislative elections, with 58 percent voting for the opposition and 42 percent for the government—the mirror image of electoral results in almost all elections since former President Hugo Chávez first took office in 1999. 

In the end, electoral dirty tricks were not enough to prevent an opposition landslide, and President Nicolás Maduro was forced to concede defeat shortly after midnight on December 7. Although the final number of opposition-held seats in the legislature is not yet certain, there are three main questions that should focus our attention over the coming weeks and months:

Venezuela’s legislative election rules are designed to over-represent the majority party and rural areas. This traditionally favored Chavista parties, but in this election, they have given the opposition a boost in the number of seats they won relative to the popular vote. The opposition has already achieved a three-fifths majority, which enables them to pass laws, approve government-proposed budgets, censure and remove government ministers and the executive vice president, and name new appointees to lead the national electoral authority and new magistrates to the Supreme Tribunal. The MUD has already promised to pass an amnesty law for political prisoners aimed at liberating a number of opposition political leaders imprisoned by the Maduro administration. It has also pledged to move legislation designed to promote economic recovery.

The opposition appears to be within striking distance of securing a two-thirds majority (112 seats), which would allow them a much wider array of powers: to remove the existing electoral authorities (with the support of the Supreme Tribunal), submit legislation to approval by popular referendum, and the equivalent of the “nuclear option” for Venezuelan legislators: convene a Constituent Assembly to write a new constitution. But with a few remaining seats in play, it appears that the MUD has more work to do to clear this hurdle and then to maintain discipline among legislators to keep a razor-thin two-thirds majority.

Either way, there is a dangerous gap between the euphoric expectations created by the elections and the actual power of the National Assembly. Not only are legislatures in Latin America typically weak, but the legislative branch has not operated independently thus far during the Chavista period. So many of its potential powers have not been exercised in practice. 

Before the vote, there was a general consensus among analysts that President Maduro would try to limit the power of the legislature in the event of an electoral loss. The tactic has many precedents, with the governments of Presidents Chávez and Maduro previously gutting the power and budgets of opposition-controlled elected offices at state and local levels.

One possibility is that the outgoing Chavista-dominated National Assembly that leaves office in January 2016 will simply pass an enabling law (Ley Habilitante) that would allow President Maduro to rule by decree for the rest of his term. There are plenty of precedents for this in Venezuela, although an enabling law that lasted for the remainder of the presidential term would be exceptional. But others have suggested that given the overwhelming opposition victory, such an approach may run too blatantly contrary to public opinion and consolidate popular sentiment against the government.

Instead, the government may simply use the Supreme Tribunal to invalidate opposition-initiated legislation. Of the 32 magistrates appointed to the highest court in Venezuela, 13 judges are retiring. Together with 5 empty seats, that will allow the outgoing legislative assembly to approve 18 new judges. These will join 12 magistrates appointed by the Chavista-controlled legislature in December 2014. With the government appointing so many members of the Supreme Tribunal, it will likely be easy for the Maduro administration to block inconvenient legislative proposals. The question for the opposition then becomes whether it can figure out how to use control of the legislature to affect the composition of the court and dilute the power of pro-government magistrates, something that would undoubtedly set off a struggle among the various branches of government.

It seems unlikely that the Chavista movement will simply accept divided government, something unknown to Venezuela since 1999. There are simply too many in the Chavista movement who cannot afford an “accountability moment” due to alleged participation in official corruption; waste, fraud, and abuse; or drug trafficking. Others will be ideologically opposed to allowing so much power to flow to an opposition-dominated national assembly.

The Chavista movement spans from the military to the governing party to armed pro-government militias and gangs (colectivos). Former President Chávez was adept at keeping the movement together. President Maduro is not nearly as skilled, and with this stunning electoral loss, his leadership within the movement (already damaged by poor economic results) is likely to come under further pressure. 

In a normal country, one might imagine some incentives for both sides to negotiate—the legislature and executive could work together to avert the coming economic catastrophe, for one. And the weakening of President Maduro’s leadership may lead to more open disagreement within Chavismo about the way ahead, allowing the possibility that moderates on both sides will find room to work together. But as journalist and long-time Venezuela observer Francisco Toro has argued, Chavismo is a machine for not negotiating; the selection process for top leadership has been designed to winnow out anyone who would consider sitting down to talk with the opposition. And in such a polarized situation, moderates always run the risk of being targeted by radicals from their own side if they negotiate with opponents.

Get the house in order

All Venezuelans should feel proud (and relieved) that these highly significant elections have been carried out peacefully. But a lot of work remains to be done. 

First, the outside study missions and electoral accompaniment missions need to remain focused on the tabulation process to ensure that the few undecided legislative seats are allocated according to electoral rules and the votes cast rather than government fiat. 

Second, Venezuela is entering a period of divided government, one that will potentially be riven by conflict among the branches of government. The outside actors that have thus far played a positive role—such as regional multilateral institutions, civil society, legislators across the hemisphere, and governments interested in supporting democracy—will need to continue to pay attention to and support favorable outcomes in Venezuela even when the country is out of the international headlines. 

And third, Venezuela’s economy is in very serious trouble now that oil has fallen as low as $35 a barrel. Further economic contraction, poverty rates not seen since before Hugo Chávez took office, and inflation in excess of 200 percent are all expected in 2016. If the government (both Chavistas and opponents) come to their senses and agree to a negotiated plan on how to address the economy, they will need the support of both traditional multilateral financial institutions and non-traditional sources of financing (such as China). 

As the opposition celebrates this major electoral win, it will undoubtedly dwell on the political implications of its victory over Chavismo. But it should not lose sight of the mandate it has now been given to make needed policy changes as well.

Update: As of December 9, 2015, media are reporting that the opposition party has won at least 112 seats, achieving a two-thirds majority in the National Assembly.

In a rare Kumbaya moment, the nation's leaders of both parties have decided that rebate checks and a flurry of other short-term measures are needed to help stave off an economic slowdown.

Unfortunately, but predictably, we're hearing far less from Capitol Hill and the campaign trail about the bigger picture and the long-term challenges facing the American economy.

Increasing competition from nations like China and India, the impending retirements of the baby boomers, and the highly unequal distribution of benefits from the recent expansion all signal the potential for slower U.S. economic growth in the future.

These challenges, and our responses, will resonate throughout the Puget Sound region.

Already, the region is one of America's economic juggernauts. According to the Paris-based Organization for Economic Cooperation and Development, the Seattle-Tacoma-Bellevue metropolitan area is the fourth-most productive in the world. And the ports of Seattle and Tacoma together form the eighth-largest gateway for foreign goods nationwide.

In that strength — and the strength of other metropolitan areas around the country — are the seeds of solutions.

Like the call for "three T's" in the stimulus debate — measures that are timely, targeted and temporary — policies to improve our nation's long-run economic performance and address its overhanging challenges would instead do well to focus on the "three I's" — innovation, intellect and infrastructure.

Innovation has always served to propel economic growth. Here, Puget Sound companies lead the world in the fields of aerospace, software and retailing, developing new ideas and products that trump the labor-cost advantages of offshoring.

Yet as a nation, we have fallen behind European competitors in innovative new-growth fields like alternative energy, where none of the world's 10 largest solar-cell manufacturers, and only one of the world's 10 largest wind-turbine manufacturers, is a U.S. company.

Intellect — the knowledge and skills of our people — translates into economic growth by raising worker output and incomes and creating more of the first "I," innovation.

Yet, while the United States sends the highest share of its young people to college worldwide, our rank falls to 16th when you measure who actually graduates. And though the Puget Sound region boasts one of the most-educated adult populations in the nation, the feeder system (especially Seattle's public schools) loses too many young people along the pathway to higher education.

Infrastructure supports long-term economic growth in many ways. High-quality transportation infrastructure — roads, transit, rail and ports — speeds the movement of goods and people within and across markets.

Yet, the Seattle area succeeds economically despite the real hurdles it faces on this front. Even taking into account high performers like Sea-Tac Airport and King County Metro, rising congestion highlights the lack of cogent plans for key corridors like Highway 520 and the Alaskan Way Viaduct, as well as the need for a renewed commitment to rail transit.

To its credit, the Puget Sound region, like other metropolitan areas around the country, has tried to tackle some of these issues on its own.

But, because the route to resolving our long-term challenges runs through areas like Seattle, its issues demand national attention.

For instance, shouldn't the federal government — through direct investments in scientific research and favorable tax treatment for corporate investment in research and development — help put innovative regions like Puget Sound ahead of the curve in cutting-edge "green" industries?

To upgrade our nation's intellectual capacity, shouldn't the federal government partner with states, localities and the private sector to support the diffusion of successful, entrepreneurial urban education models for districts like Seattle?

And on infrastructure, shouldn't the federal government deploy its roughly $50 billion in annual transportation expenditures in smarter ways to help relieve congestion and promote sustainability in key trade corridors like the Seattle-Tacoma area?

Once we get past the stimulus frenzy, let's have a real debate about the blueprint for bolstering America's long-term economic growth.

Building on the strengths, and addressing the challenges, of the "three I's" in regions like Seattle ought to be another strategy leaders in our nation's capital can agree upon.

Alan Berube is research director of the Metropolitan Policy Program at the Brookings Institution in Washington, D.C. David Jackson is a policy analyst with the program.

While much of the outside world has focused on the current wave of violence in Israel and the West Bank, far less attention is paid to the causes behind it and the context in which it is occurring. In meetings last month in Ramallah and Jerusalem with a range of Palestinian politicians, journalists, and analysts, as well as with senior U.S. officials, it was clear that the attacks reflect the deepening anger and despondency among Palestinians.

The current violence is largely despair-driven, but remains individualistic and politically directionless. Palestinians use different terms to describe the current violence. Popularly, and in most local media, it is known as the “Jerusalem Intifada.” But unlike previous Palestinian uprisings, this latest wave of violence lacks both political organization and clear political demands. 

The fact that so many young Palestinians are willing to risk almost certain death in order to carry out otherwise ineffective stabbing attacks on Israelis points to a deep sense of hopelessness and despair. It’s not only that Israeli settlement expansion, home demolitions, land confiscations, and movement restrictions continue to rob Palestinians of their land, livelihoods, and dignity; it’s that Palestinians now must endure Israel’s seemingly endless occupation without any of the “safety nets” they traditionally have fallen back on: the peace process is dead, Arab regional support and solidarity has evaporated, and their political leaders (both secular and Islamist) are ineffective and increasingly discredited. 

In short, Palestinians feel a deep sense of abandonment by the international community, their fellow Arabs, and even their own leaders. Although domestic political considerations as well as Abbas’ own waning credibility have constrained the leadership’s ability to disavow the violence outright, the Palestinian Authority (PA) continues to work quietly with the Israelis to keep the situation under control. The main question now, particularly for U.S. officials, is how long this PA security coordination with Israel can continue given mounting public opposition and the precipitous decline in international aid, which according to the World Bank is down by roughly 60 percent.

As confidence in Abbas’ leadership declines, Palestinian political stagnation and dysfunction is likely to continue. Since a public opinion poll published last September found that an unprecedented two-thirds of Palestinians wanted Abbas to resign, popular frustration with the Palestinian leader seems only to have grown. Many Palestinians lament what they see as the transformation of their national movement from groups and leaders dedicated to national liberation to a ruling class with special privileges (VIP status, travel, etc.) and a stake in the status quo. Even American officials seemed alarmed by the extent to which the PA is now perceived as a “collaborationist” government by ordinary Palestinians. 

At the same time, Abbas’ leadership style and decision-making are also alienating much of the political elite, including within his own Fatah movement. Several Palestinian officials were privately critical of Abbas. Others have been more open in their criticism, including former West Bank security chief Jibril Rajoub, who recently railed against Abbas and his inner clique in a lengthy interview on Palestinian TV. 

Much of the internal frustration with Abbas has to do with recent leadership appointments as well as what many see as his growing paranoia and personal vendettas against perceived rivals like Salam Fayyad, Yasser Abed-Rabbo, and his arch-nemesis, Mohamed Dahlan, the now-exiled former Gaza security chief. Both of these underscore the growing anxiety over the lack of clarity regarding a future succession process (on which I will have more to say in a subsequent post). Many also voiced skepticism about Abbas’ current diplomatic strategy, which is focused on building support for an international peace conference. While most Palestinians support internationalization, and virtually no one supports a return to U.S.-led peace negotiations, there are doubts as to whether Abbas’ international efforts are rooted in a broader strategy. 

The lack of strategic thinking is also fueling frustration over the ongoing stalemate with Hamas in Gaza. Indeed, many view Abbas as the primary obstacle to Gaza reconstruction and progress toward reconciliation with Hamas. Despite Hamas’ clear weakness since 2013, Abbas has been loath to give Hamas anything it could claim as a political concession and is equally reluctant to inherit responsibility for Gaza’s myriad social, economic, and security problems, for which he currently has no solutions. 

[T]here is a growing feeling, both within Fatah and beyond, that things are unlikely to change internally (and perhaps even diplomatically) until Abbas has left the scene.

Consequently, there is a growing feeling, both within Fatah and beyond, that things are unlikely to change internally (and perhaps even diplomatically) until Abbas has left the scene. At the same time, despite the growing frustration with Abbas, most are not eager to accelerate his departure. As I have written elsewhere, the absence of credible alternatives has given Abbas a sort of “legitimacy by default.” This may explain Abbas’ otherwise inexplicable complacency and his sense, as I was repeatedly told, that time is on his side.

Gaza’s Hamas rulers face their own set of equally daunting political, economic, and security challenges. Although I did not visit Gaza or meet with any Hamas representatives, both figured prominently in most of my discussions. Hamas continues to face serious financial problems as a result of the virtual elimination of its tunnels network and the closure of the Rafah border crossing. The scarcity of resources, a major factor in Hamas’ decision to pursue reconciliation with the PA in 2014, is also fueling tensions within the movement. Whereas Hamas’ military wing, the al-Qassam Brigades, seeks to rebuild its military capabilities and restore its ties with Iran, its political leadership is equally keen to avoid another military confrontation with Israel and hopes to capitalize on diplomatic openings with Turkey and Saudi Arabia. 

The main security threat to Hamas rule comes from jihadi groups, most notably Jaysh al-Islam in the Gaza Strip and the Sinai-based Ansar Beit al-Maqdis, both of which have pledged allegiance to ISIS and regard Hamas (as well as its parent, the Muslim Brotherhood) as apostates. Despite occasional tit-for-tat attacks, at the moment neither Hamas nor the jihadis appear eager for a major fight. The potential for escalation remains, however, particularly if jihadi groups decide to exploit internal discontent within Hamas or force its hand militarily by launching rocket attacks on Israel. Such internal instability, along with the slow pace of reconstruction and already abysmal economic and humanitarian conditions in Gaza, highlights the ever-present danger of yet another devastating war between Israel and Hamas. 

In the end, while the outside world’s preoccupation with the current wave of violence is understandable, merely condemning ad hoc violence by Palestinians while failing to address the deeper, institutionalized violence of the Israeli occupation is both morally dishonest and politically untenable.

Good morning and welcome to the "future." At approximately 4:29 p.m. Hill Valley time on Oct. 21, Doc Brown and Marty McFly arrive at the present day. For many millennials especially, the 1985 film series Back to the Future represented the far-flung fantastical future that many dreamed would come. But how does the Reagan-era vision of a future where we don't need roads compare to our daily lives today?

Sadly, you probably came to work today on the same street you may have trodden as a child back in 1985 without a hover board. But our future is still pretty fantastic, and many of the outlandish futuristic devices you saw in the 1989 film Back to the Future II are closer than you think—or already here. Here are three predictions that the film made that today might actually turn the head of an ‘80s time traveler

Drone proliferation

When Doc Brown and Marty McFly arrived in 2015, the sky was filled with more flying cars than the drones that sometimes dot our skies, but the film did point to some potential uses for unmanned remote flying devices. In the future, the film envisioned drones for walking the dog and even remote photography drones reporting on the day's news. While drones today don't exactly fill these roles, that future is perhaps closer than you think.

"Private actors will soon operate drones in equal if not greater numbers than the government," Brookings Fellow Wells Bennett wrote in a report on civilian use of drones last year. Amazon has tested drones to aid in home and business delivery. CNN has been given clearance by the government to explore the use of drones for reporting. Even law enforcement and public safety officials have used drones to aid in policing and fighting fires.

The widespread use of drones in daily life is probably still part of our future rather than our present in 2015, but regulations for this future are being written today. Federal regulators just this week announced that recreational drones will need to be registered. Last year as part of our project on civilian robotics, Gregory McNeal offered his own suggestions for federal and state regulators on how best to tackle civilian drone regulations.

Cybernetic humans and wearable technology

In the 1989 film, Marty faces off against his son's cybernetic bully, Griff Tannen. The bullies of the present don't exactly resemble Griff or Locutus of Borg, but cybernetics is closer than you think—even resting in your palm right now.

Taking a walk through Hill Valley in the real 2015, a time traveler might see several pedestrians immersed in their smartphones or glancing at notifications on their wearable devices. In our homes, virtual reality is becoming more prominent as well. Systems like Oculus and Google Cardboard resemble very closely the remote television visors worn by Marty's kids in the future.

"The proverbial visitor from Mars might conclude that [cell phones] were an important feature of human anatomy," Chief Justice John Roberts wrote in a 2014 opinion referencing the cybernetic future we are living today. Benjamin Wittes and Jane Chong acknowledge in their report on the emerging cyborg future that the connection we have with technology is becoming more personal. While surveillance laws of the past might make distinctions between human tissue and the devices we use in our daily lives, Wittes and Chong argue that perhaps the separation between the human being and technology in some cases is no longer there—and the law should adapt to acknowledge this.

Flying cars and the transportation of the future

The most-often panned prediction of the film is admittedly the most disappointing—there are no flying cars in our future. This has been a fantasy for even Baby Boomers who were thrilled by the Jetsons' view of the 21st Century. Flying cars do exist in a limited form, but they are more accurately described as ultra-portable planes that require a pilot’s license to fly. However, the future of transportation is even better than Marty or Doc Brown ever realized; they just needed to travel a few more years in the future to see it happen.

Driverless cars have the potential to be the biggest seismic shift in transportation that many of us will experience in our lifetime. Numerous automotive makers and even Google are preparing for the autonomous future. Imagine your vehicle circling the parking lot to pick you up after a film; traversing rush hour traffic to deliver your daughter to softball practice; even serving as designated driver on Friday night after drinks at the bar.

The future seems like a fantasy, but liability concerns about whom to sue when an automated vehicle gets in a fender bender—or worse—clouds this would-be future.

"While liability will always be important with respect to motor vehicle operation, automation will dramatically increase safety on the highways by reducing both the number and severity of accidents," writes John Villasenor in his report on how to tackle liability in the driverless era. Despite many reservations about driverless cars, Villasenor argues that current liability law frameworks would be well equipped to address concerns.

Of course, whether the DeLorean Motor Company will come out of mothballs and produce a driverless DeLorean remains to be seen.

Discuss the future's impact on the modern workforce

At least according to Robert Zemeckis, we've arrived in the future. Not that you’re here, join us at 2 p.m. Oct. 26 when we'll discuss one of the important consequences of all of this technological automation: its impact on the workforce and the availability of social benefits.

“If the Americans and their regional allies want to pass through the Strait of Hormuz and threaten us, we will not allow any entry,” said deputy commander of Iran’s Revolutionary Guards, Hossein Salami, last Wednesday. Iran has a long history of making threats against this critical waterway, through which some 17 million barrels of oil exports pass daily, though it has not carried them out. But multiple regional security threats highlight threats to energy transit from and through the Middle East and North Africa (MENA)—and demand new thinking about solutions.

Weak spots

Hormuz attracts attention because of its evident vulnerability. But recent years have seen severe disruptions to energy flows across the region: port blockades in Libya; pipeline sabotage in Egypt’s Sinai, Yemen, Baluchistan in Pakistan, and Turkey’s southeast; attacks on oil and gas installations across Syria and Iraq; piracy off Somalia. Energy security is threatened at all scales, from local community disturbances and strikes, up to major regional military confrontations.

Of course, it would be best to mitigate these energy security vulnerabilities by tackling the root causes of conflict across the region. But while disruption and violence persist, energy exporters and consumers alike should guard against complacency.

A glut of oil and gas supplies globally—with low prices, growing U.S. self-sufficiency, and the conclusion of the Iranian nuclear deal—may seem to have reduced the urgency: markets have hardly responded to recent flare-ups. But major economies – even the United States – still remain dependent, directly or indirectly, on energy supplies from the MENA region. Spare oil production capacity is at unusually low levels, leaving the balance vulnerable to even a moderate interruption.

Most concern has focused on oil exports, given their importance to the world economy. But the security of liquefied natural gas (LNG) shipments is an under-appreciated risk, particularly for countries such as Japan and South Korea which are heavily dependent on LNG. A disruption would also have severe consequences for countries in the Middle East and North Africa, depriving them not only of revenues but potentially of critical imports.

Doing better 

There are three broad groups of approaches to mitigating the risk of energy transit disruptions: infrastructure, institutions, and market. 

1. Infrastructure includes the construction of bypass pipelines avoiding key choke-points and strategic storage.
   
   Existing bypass pipelines include SUMED (which avoids the Suez Canal); the Habshan-Fujairah pipeline in the UAE (bypassing Hormuz); and the Saudi Petroline, which runs to the Red Sea, hence offering an alternative to the Gulf and Hormuz. Proposed projects include a link from other Gulf Cooperation Council (GCC) countries to Oman’s planned oil terminal at Duqm on the Indian Ocean; new or rehabilitated pipelines from Iraq across Jordan and Turkey; an expansion of Petroline; and a new terminal in southern Iran at Jask.
   
   Strategic storage can be held by oil exporters, by importers, or a combination (in which exporters hold oil close to their customers’ territory, as with arrangements between Saudi Arabia and Japan, and between Abu Dhabi and Japan and India).


2. Institutional approaches include mechanisms to deal with disruptions, such as cooperative sharing arrangements.
   
   More analysis has focused on infrastructure than on institutional and market mitigation. Yet these approaches have to work together. Physical infrastructure is not enough: it has to be embedded in a suitable framework of regulation, legislation, and diplomacy. Cross-border or multilateral pipelines require agreements on international cooperation; strategic storage is most effective when rules for its use are clear, and when holders of storage agree not to hoard scarce supplies. 
   
   The effective combination of infrastructure and institutions has a strategic benefit even if it is never used. By making oil exporters and consumers less vulnerable to threats, it makes it less likely that such threats will be carried out.
   
   Alliances can be useful for mutual security and coordination. However, they raise the difficult question of whom they are directed against. Mutually-hostile alliances would be a threat to regional energy security rather than a guarantor. Organizations such as the International Energy Agency (IEA), the International Energy Forum (IEF), Organization of Petroleum Exporting Countries (OPEC), Gulf Cooperation Council, and the Association of Southeast Asian Nations (ASEAN) could all have roles, but none is ideally placed. Rather than creating another organization, reaching an understanding between existing bodies may be more effective.


3. In general, markets cope well with the task of allocating scarce supplies. Better and timelier data, such as that gathered by the IEF, can greatly improve the functioning of markets. Governments do have a role in protecting the most vulnerable consumers and ensuring sufficient energy for critical services, but price controls, rationing, and export bans have usually been counterproductive, and many of the worst consequences of so-called energy crises have come from well-meaning government interference with the normal market process of adjustment.
   
   However, it is generally difficult or impossible for a single company or country to capture all the benefits of building strategic infrastructure—which, as with a bypass pipeline, may only be required for a few months over a period of decades. International financing, perhaps backed by a major energy importer—mostly likely China—can help support such projects, particularly at a time of fiscal austerity in the Middle East.

Energy exporters within the MENA region may often find their interests divergent. But the field of energy security is one area for more fruitful cooperation—at least between groups of states, and some external players, particularly their increasingly important Asian customers. If regional tensions and conflicts cannot be easily solved, such action at least alleviates one of the serious risks of the region’s turmoil.

For more on this topic, read Robin Mills’ new analysis paper “Risky routes: Energy transit in the Middle East.”

INTRODUCTION

In December 2011, the United Nations State of the World’s Volunteering Report was released at the U.N. headquarters in New York along with a General Assembly resolution championing the role of volunteer action in peacebuilding and development. The United Nations Volunteers (UNV) Program report states that:

The contribution of volunteerism to development is particularly striking in the context of sustainable livelihoods and value-based notions of wellbeing. Contrary to common perceptions, the income poor are as likely to volunteer as those who are not poor. In doing so, they realize their assets, which include knowledge, skills and social networks, for the benefit of themselves, their families and their communities…Moreover, volunteering can reduce the social exclusion that is often the result of poverty, marginalization and other forms of inequality…There is mounting evidence that volunteer engagement promotes the civic values and social cohesion which mitigate violent conflict at all stages and that it even fosters reconciliation in post-conflict situations...

The “South Africa Conference on Volunteer Action for Development” convened in Johannesburg in October 2011, and the July 2012 “Africa Conference on Volunteer Action for Peace and Development” co-hosted with the Kenya’s Ministry of East African Community, the United Nations and partners in Nairobi give further evidence to the rise of and potential for volunteer service to impact development and conflict. Indeed, in the aftermath of the 2011 Arab Spring, youth volunteer service and empowerment have emerged as a pivotal idea in deliberations aimed at fostering greater regional cohesion and development.

In “Foresight Africa: Top Priorities for the Continent in 2012,” Mwangi S. Kimenyi and Stephen N. Karingi note that: “One of the most important pillars in determining whether the positive prospects for Africa will be realized is success in regional integration… This year is a crucial one for Africa’s regional integration project and actions by governments, regional organizations and the international community will be critical in determining the course of the continent’s development for many years to come.”

The authors note the expected completion of a tripartite regional free trade agreement by 2014 and the expected boost to intra-African trade, resulting in an expanded market of 26 African countries (representing more than half of the region’s economic output and population). At the same time, the declaration from the “South Africa Conference on Volunteer Action for Development” calls on “Governments of Southern African member states and other stakeholders to incorporate volunteering in their deliberations from Rio +20 and to recognize the transformational power as well as economic and social value of volunteering in achieving national development goals and regional priorities, which can be achieved by facilitating the creation of an enabling environment for volunteering to support, protect and empower volunteers.” This speaks directly to the urgent need to factor the social dimension into the regional integration agenda in the different African subregions.

This paper includes examples of the growth of volunteer service as a form of social capital that enhances cohesion and integration across three regions: southern, western, and eastern Africa. It further highlights civil society best practices and policy recommendations for increased volunteering in efforts to ensure positive peace, health, youth skills, assets and employment outcomes.

The importance of volunteering to development has been noted in recent United Nations consultations on the Rio+20 convening on sustainable development and the post-2015 development framework. As the U.N. reviews its Millennium Development Goals (MDG) process, Africa’s regional service initiatives offer vital lessons and strategies to further achieve the MDGs by December 2015, and to chart the way forward on the post-2015 development framework.

But how does volunteerism and civic service play out in sub-Saharan Africa? What are its institutional and non-institutional expressions? What are the benefits or impacts of volunteerism and civic service in society? Our specific purpose here is to provide evidence of the different manifestations and models of service, impact areas and range of issues in three African regions. In responding to these questions, this analysis incorporates data and observations from southern, western and eastern Africa.

In conclusion, we provide further collective insights and recommendations for the roles of the Africa Union and regional economic communities (RECs), youth, the international community, the private sector and civil society aimed at ensuring that volunteerism delivers on its promise and potential for impact on regional integration, youth development and peace.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Photo: Paul Morigi

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

1. Set bold goals

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

2. Hybridize the best of public and private sectors

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

3. Data, data, data

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

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

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

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

Fred Dews and Andrew Kenealy contributed to this post.

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

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

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

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

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

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

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

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

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

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

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

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

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

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