This summer, the world has watched as an al Qaeda offshoot, the Islamic State group, launched a militant offensive into Iraq, seizing large swaths of land. This Center for Middle East Policy’s Middle East Memo, Kurdistan Rising: To Acknowledge or Ignore the Unraveling of Iraq, examines how the fall of Iraq’s key city of Mosul has changed matters for Kurds in Iraq, and the necessity for American policymakers to take stock of the reality of the Kurdistan Region in this “post-Mosul” world.

Highlights: 

• A look at the Kurds of Iraq, their history and how the United States has largely spurned a partnership with them. Having been autonomous in Iraq since 1991, the Kurds heeded the aspirations of the United States in 2003 to assist in the removal of the Baath regime of Saddam Hussein, and played by the rules of the game established in the post-2003 period, albeit unwillingly at times. However, they have consistently refused to follow a path that would result in relinquishing the powers they enjoy. They have even taken steps to extend their autonomy to the point of having economic sovereignty within a federal Iraq, thus bringing them into serious dispute with Baghdad and the government of Nouri al-Maliki and earning the rebuke of the United States.

• An examination of how, since 2011, failed U.S. and European policies aimed at healing Iraq’s sectarian and ethnic fissures have contributed to the current situation. By so strongly embracing the concept of Iraq’s integrity as crucial to American interests in the region, key allies and partners have been marginalized along the way.

• Policy recommendations for the United States and its western allies, given that the Kurdistan region now stands on the threshold of restructuring Iraq according to its federal or confederal design, or exercising its full right to self-determination and seceding from Iraq. By ignoring the realities of Kurdish strength in Iraq, U.S. and European powers run the risk of losing influence in the only part of Iraq that can be called a success story, and antagonizing what could be a key ally in an increasingly unpredictable Middle East.

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• Kurdistan Rising: To Acknowledge or Ignore the Unraveling of Iraq

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.

Dear Members of the Senate,

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

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

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

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

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

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

Very truly yours,

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

Gregory Koger
Associate Professor of Political Science, University of Miami

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

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

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

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

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

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

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• Download the Original Letter

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.

Editors’ Note: Outgoing British Prime Minister David Cameron once proudly stated that "there is no country in the Western world more open to Chinese investment than Britain." What will happen to the Sino-British relationship now that the U.K. will almost certainly leave the EU? This post originally appeared in the Nikkei Asia Review.

One of the many side effects of the June 23 British referendum on the European Union is that it will put an end to a honeymoon that had barely started less than a year ago, when George Osborne, the U.K.'s chancellor of the exchequer, declared on the eve of Chinese President Xi Jinping's state visit to Britain: "Let's stick together and make a golden decade for both our countries." Much has happened since the visit, during which Xi was feted as a guest of honor by Queen Elizabeth II at Buckingham Palace and at the British Parliament.

Over the past three years, British Prime Minister David Cameron and Osborne, (the man in effect running the country's China policy), seem to have partly anticipated the referendum's outcome by partnering with a few Asian countries outside the European Union—China especially—that would help finance some of the major infrastructure projects needed by the U.K., including nuclear plants, high-speed railways and airport infrastructure.

Now, in the turmoil following the referendum, Cameron is on the way out and Osborne's future remains uncertain. What will happen to the Sino-British relationship now that the U.K. will almost certainly leave the EU? Initial signals from China have been subdued. Foreign Ministry spokeswoman Hua Chunying recently said she believed that the impact of Brexit will be at all levels—not only in relations between China and Britain.

"China supports the European integration process and would like to see Europe playing a proactive role in international affairs. We have full confidence in the outlook for the development of China-EU ties," she said. This is a far cry from the enthusiastic comments in Chinese media on the Sino-British relationship in 2015, when Britain decided—much to the chagrin of Washington, Tokyo, Berlin and Paris—to be the first Western country to join the China-backed Asian Infrastructure Investment Bank (AIIB) and when it hosted Xi, hoping to attract massive Chinese foreign direct investment.

Cameron had proudly stated that "there is no country in the Western world more open to Chinese investment than Britain." The U.K. is currently Europe's top destination for Chinese FDI with a cumulative investment of $16.6 billion in the country since 2000 (including $3.3 billion in 2015 alone), and many memoranda of understanding signed during Xi's visit last fall. Will these be completed now that the British people have voted to leave the EU? A few months ago, Wang Jianlin, the head of China's Dalian Wanda Group—a commercial property and cinema chain operator—and a major investor in Europe warned: "Should Britain exit the EU, many Chinese companies would consider moving their European headquarters to other countries," adding that "Brexit would not be a smart choice for the U.K., as it would create more obstacles and challenges for investors and visa problems."

The Global Times, an English-language publication that is part of the Chinese Communist Party's People's Daily, was even less sympathetic to the British situation, writing in an editorial after the referendum, that the vote would "probably be a landmark event that proves Britain is heading in the direction of being a small country with few people, writing itself off as hopeless and acting recklessly."

The Beijing leadership—which uniquely went out of its way to support the Remain camp on several occasions—is puzzled by the referendum's result, which has not only created some disorder (an unbearable word in official party language) but also led to the resignation of the country's prime minister and the risk of further pro-autonomy referenda (namely, in Scotland). In the eyes of a communist party fully focused on retaining all its powers, Cameron made a serious mistake as the leader of a major country.

After all, China has no soft intentions toward the U.K. The two countries have had a complicated history. The Chinese still call the period starting in the mid-1800s— which included the British-led Opium Wars—the "century of humiliation." And it has only been 19 years since Hong Kong was returned to the motherland as a Chinese "special administrative region (SAR)." Not that the Cameron government has done very much to support its former territory: As the "golden decade" was unfolding, Hong Kong faced one of its most difficult times, with arrests of dissidents and the disappearance of some booksellers—including Lee Bo, who holds dual Sino-British citizenship and had published controversial books about Chinese leaders.

Now that British voters have spoken, chances of a backlash are running high. For a start, China is keen on keeping close involvement with the EU—its second-largest trading partner after the U.S., a source of technology transfers, and an ally in Beijing's "One Belt, One Road" projects in Europe and Asia, or in initiatives such as the AIIB and the country' Silk Road fund. In this respect China will almost certainly want to continue its close partnership with both EU institutions and individual countries, especially in Eastern and Central Europe where "One Belt, One Road" has been warmly welcomed. (Two countries recently visited by Xi, Poland and the Czech Republic, received substantial financial commitments from the Chinese president.)

London will, of course, continue to play a key role in finance as one of the world's top international trading platforms with Chinese treasury bonds issued in renminbi. Chinese visitors (including property buyers looking for fresh opportunities) will continue to flock to the city. But when it comes to being China's bridge to the EU, it is clear that Beijing will look for alternatives, particularly Germany, which is China's top economic partner in Europe. German Chancellor Angela Merkel recently made her ninth visit to China and managed to address a long list of key issues, including trade, investment and reciprocity, as well as human rights, new laws regulating nongovernment organizations and territorial claims in the South China Sea. In a powerful speech to Nanjing University students in Beijing on June 12, she stressed that the trust of the citizens can only be achieved by the rule of law, "rather than rule by law." It has been many years since British leaders have used this language in China. Even though some British politicians are now calling for a reassessment of the country's China policy, it is unlikely that the U.K. will do anything but accommodate China in order to preserve trade and investment in the post-Brexit uncertainty.

For all its openness, the "new U.K." will become less attractive market-wise. After Brexit, China will also lose a proponent of free trade within the EU—that is bad news as the 28-nation block is pondering the decision to grant market economy status to China, in accordance with an agreement under the World Trade Organization. Market economy status affects the way anti-dumping duties are used. Job-wise, the European steel industry is vulnerable. Since the adoption by the European Parliament of a nonbinding resolution against granting market economy status to China on May 12, many European politicians fear that more Chinese economic involvement in their home countries would lead to more cheap goods competing with European-made products and fewer jobs at home—hence a less favorable context for China. The chances of an EU-China free-trade agreement are becoming more remote now as the EU is more focused on finalizing a comprehensive agreement on investment with China. European companies have been lobbying for such a pact.

Although it will almost certainly make the most of an autonomous U.K. after conducting its own assessment, China does not like uncertainty—especially in turbulent times both at home and abroad. It worries about challenges against ruling parties, as well as an anti-globalization attitude that could affect its own image as a beneficiary of globalization. As for Europe, both Germany and France have strong relations with China. With their backing, the European Commission has just published an ambitious new strategy on China. It looks like the U.K. will not be part of it.