"It is fortunate that a major feature of American social policy is a series of programs, often referred to as the safety net, that are designed to provide people with cash and other benefits when they fall on hard times—which they are more likely to do during a recession," write the authors of a new report on the response of the Temporary Assistance for Needy Families (TANF) program—the major federal welfare program that replaced Aid to Families with Dependent Children (AFDC) in 1996—to the Great Recession that lasted from December 2007 to June 2009.

In their report, "The Responsiveness of the Temporary Assistance for Needy Families Program during the Great Recession," Ron Haskins, Vicky Albert, and Kimberly Howard write that "All in all, we conclude that the American system of balancing work requirements and welfare benefits worked fairly well, even during the most severe recession since the Depression of the 1930s."

Their report is based on three studies: (1) an examination of the changes in the TANF rolls compared to changes in AFDC rolls during previous recessions, plus changes in TANF rolls in relation to rising unemployment state-by-state; (2) a review of data on single mothers' likelihood to receive TANF benefits during the 2001 and 2007 recessions, their receipt of other program benefits, and what actions single mothers took to deal with the recession; and (3) interviews with 44 directors of state TANF programs to determine their state's response.

"An important question" noted by the authors at the outset "is whether the response of the nation's safety net program in general and the TANF program in particular was commensurate with the challenge posed by the huge level of unemployment during and following the Great Recession."

Some Results of the TANF Study

Haskins, Albert, and Howard arrived at a number of conclusions from the TANF/AFDC study, including:

• TANF rolls increased more in the 2001 recession and the 2007 Great Recession than did AFDC during previous, pre-welfare reform (1996) recessions.
• The increase in TANF rolls was greater during the period of rising unemployment in each state, which did not coincide exactly with the dates of the Great Recession, than during the official recession period nationally.
• The "nation's safety net as a whole performed well during the Great Recession and prevented millions of people from falling into poverty."

"The nation experienced 51 different recessions and 51 different responses by the TANF program to the recession,” they write. "But the key point is that measuring the rise of the TANF caseload in response to the unique increase in unemployment in each state reveals TANF to have been more responsive to the recession."

Some Results of the Single Mothers Study

• Compared with the 1990 recession before welfare reform, "single mothers were less likely to receive benefits from the TANF program during the 2001 and 2007 recessions."
• Single mothers were more likely to receive other "safety net" help such as Unemployment Compensation, Supplemental Nutrition Assistance Program (formerly food stamps), Supplemental Security Income, the Earned Income Tax Credit, and child care, school lunch and breakfast, and other benefits for their children.
• In all the 1990, 2001, and 2007 recessions, "single mothers took action on their own" by finding jobs, living with family, and other ways to "weather the recession."
• Based on income, "poverty among single mothers and their children was lower during the Great Recession than during the recession of 1990."

Given the array of available benefits, the authors conclude that:

a mother with two children earning even as little as $11,000 per year could and still can escape poverty, as measured by income that includes non-cash benefits and tax credits, because of the generosity of these benefits. In our view, the combination of strong work requirements and generous work support benefits is a reasonable policy, despite the fact that fewer mothers receive TANF now than in the past.

Some Results of the TANF Directors Study

"Arguably the people who know the most about the goals and operation of state TANF programs and how the programs responded to the recession are the state TANF directors," write Haskins, Albert, and Howard. "They were, after all, the point persons for state TANF programs before and during the Great Recession. Interviews with TANF directors can provide an insider's view of the TANF issues that we have so far analyzed from the outside." Some of their conclusions from these interviews include:

• Most states did not struggle to pay for growing TANF rolls during the Great Recession.
• Most state directors considered their state's response to the recession "as adequate or better."
• The directors had suggestions for improving the TANF program, including having more flexibility in work participation rates, gaining access to the Contingency Fund, and placing greater emphasis on job training.

Some Policy Recommendations

Although the authors believe that the TANF program worked well, especially in conjunction with other safety net programs, they suggest some potential reforms:

• TANF allows vocational training to count toward states fulfilling their work requirement, but only a maximum of 30 percent of the work requirement can be fulfilled by TANF recipients in education or training. In times of high unemployment, Congress could raise the percentage limit from 30 to 40 or even 50 percent when unemployment reaches some specified level in the state, given that most experts believe the unemployed should expand their skills through job training during recessions.
• Congress should consider changing the 12-week limit on job search during periods of high unemployment to as much as six months, given that the average period of search before finding a job increases sharply during periods of high unemployment.

Download and read the full report for complete methodology, analysis, and data.

In December 2009, the Saban Center for Middle East Policy conducted a day-long simulation of the diplomatic and military fallout that could result from an Israeli military strike against the Iranian nuclear program. In this Middle East Memo, Kenneth M. Pollack analyzes the critical decisions each side made during the wargame.

The simulation was conducted as a three-move game with three separate country teams. One team represented a hypothetical American National Security Council, a second team represented a hypothetical Israeli cabinet, and a third team represented a hypothetical Iranian Supreme National Security Council. The U.S. team consisted of approximately ten members, all of whom had served in senior positions in the U.S. government and U.S. military. The Israel team consisted of a half-dozen American experts on Israel with close ties to Israeli decision-makers, and who, in some cases, had spent considerable time in Israel. Some members of the Israel team had also served in the U.S. government. The Iran team consisted of a half-dozen American experts on Iran, some of whom had lived and/or traveled extensively in Iran, are of Iranian extraction, and/or had served in the U.S. government with responsibility for Iran.

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In the early hours of Sunday June 12, 2016, a madman perpetrated the mass murder of 49 people in a nightclub considered a safe space for Orlando’s LGBT community. 

Politicians quickly went into gear to exploit this tragedy to push their own agendas. Glaringly silent on the civil rights of LGBT communities, Donald Trump and Ted Cruz repeated their calls to ban, deport, and more aggressively prosecute Muslims in the wake of this attack. As if Muslims in America are not already selectively targeted in counterterrorism enforcement, stopped for extra security by the TSA at airports, and targeted for entrapment in terrorism cases manufactured by the FBI. 

Other politicians reiterated calls for Muslim communities to fight extremism purportedly infecting their communities, all while ignoring the fact that domestic terrorism carried out by non-Muslim perpetrators since 9/11 has had a higher impact than the jihadist threat. Asking Muslim American communities to counter violent extremism is a red herring and a nonstarter. 

In 2011, the White House initiated a countering violent extremism (CVE) program as a new form of soft counterterrorism. Under the rubric of community partnerships, Muslim communities are invited to work with law enforcement to prevent Muslims from joining foreign terrorist groups such as ISIS. Federal grants and rubbing elbows with high level federal officials are among the fringe benefits for cooperation, or cooptation as some critics argue, with the CVE program. 

Putting aside the un-American imposition of collective responsibility on Muslims, it is a red herring to call on Muslims to counter violent extremism. An individual cannot prevent a criminal act about which s/he has no knowledge. Past cases show that Muslim leaders, or the perpetrators’ family members for that matter, do not have knowledge of planned terrorist acts. 

Hence, Muslims and non-Muslims alike are in the same state of uncertainty and insecurity about the circumstances surrounding the next terrorist act on American soil. 

CVE is also a nonstarter for a community under siege by the government and private acts of discrimination. CVE programs expect community leaders and parents to engage young people on timely religious, political, and social matters. While this is generally a good practice for all communities, it should not be conducted through a security paradigm. Nor can it occur without a safe space for honest dialogue.

After fifteen years of aggressive surveillance and investigations, there are few safe spaces left in Muslim communities. Thanks in large part to mass FBI surveillance, mosques have become intellectual deserts where no one dares engage in discussions on sensitive political or religious topics. Fears that informants and undercover agents may secretly report on anyone who even criticizes American foreign policy have stripped mosques from their role as a community center where ideas can be freely debated. Government deportations of imams with critical views have turned Friday sermons into sterile monologues about mundane topics. And government efforts to promote “moderate” Muslims impose an assimilationist, anti-intellectual, and tokenized Muslim identity. 

For these reasons, debates about religion, politics, and society among young people are taking place online outside the purview of mosques, imams, and parents. 

Meanwhile, Muslim youth are reminded in their daily lives that they are suspect and their religion is violent. Students are subjected to bullying at school. Mosques are vandalized in conjunction with racist messages.  Workers face harassment at work. Muslim women wearing headscarves are assaulted in public spaces. Whether fear or bigotry drives the prejudice, government action and politicians’ rhetoric legitimize discrimination as an act of patriotism.

Defending against these civil rights assaults is consuming Muslim Americans’ community resources and attention. Worried about their physical safety, their means of livelihood, and the well-being of their children in schools; many Muslim Americans experience the post-9/11 era as doubly victimized by terrorism. Their civil rights are violated by private actors and their civil liberties are violated by government actors—all in retribution for a criminal act about which they had no prior knowledge, and which they had no power to prevent by a criminal with whom they had no relationship.

To be sure, we should not sit back and allow another mass shooting to occur without a national conversation about the causes of such violence. But wasting time debating ineffective and racialized CVE programs is not constructive. Our efforts are better spent addressing gun violence, the rise of homophobic violence, and failed American foreign policy in the Middle East.

We all have a responsibility to do what we can to prevent more madmen from engaging in senseless violence that violates our safe spaces.

This article was originally published in the Huffington Post.

The city of Chicago is increasing retrofits by using stimulus dollars to expand the opportunity for energy efficient living to low-income residents of large multi-family rental buildings. To aid this target demographic, often left underserved by existing programs, the city’s new Multi-Family Energy Retrofit Program introduces an innovative model for retrofit delivery that relies on private sector financing and energy service companies.

Chicago’s new Multi-Family Energy Retrofit Program draws on multi-sector collaboration, with an emphasis on private sector involvement supported by public and nonprofit resources. Essentially, the program applies the model of private energy service companies (ESCOs), long-used in the public sector, to the affordable, multi-family housing market. In this framework, ESCOs conduct assessments of building energy performance, identify and oversee implementation of cost-effective retrofit measures, and guarantee energy savings to use as a source of loan repayment.

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Youth summer jobs programs have experienced a resurgence of interest and investment since the Great Recession, driven by concerns about high unemployment rates among young people, particularly those who are low-income, black, or Hispanic. Recent research points to summer jobs programs as a positive lever for change by reducing violence, incarceration, and mortality and improving academic outcomes.They are often a jurisdiction’s most high-profile youth employment initiative.

But good intentions do not always lead to results. Research has not yet linked summer jobs programs to improved employment outcomes, evaluations to date are silent on effective program design, and in the absence of agreed-upon standards and best practices, there is no guarantee of quality.They are complicated and labor-intensive to operate, and many jurisdictions had to re-build their programs after a long hiatus following the end of dedicated federal funding in the late 1990s.

On Thursday, July 14, the Brookings Metropolitan Policy Program hosted an event that explored core elements associated with high-performing programs and made recommendations to strengthen summer jobs programs. The event featured a presentation on the finding of a new paper by Brookings fellow Martha Ross and co-author Richard Kazis, titled, “Youth Summer Jobs Programs: Aligning Ends and Means,” followed by a response panel, comprised of leaders from metro areas across the country.  

Join the conversation on Twitter at #SummerJobs

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• Welcome and presentation
• Panel discussion
• Closing remarks

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• Improving youth summer jobs programs

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• Uncorrected Transcript (.pdf)

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• 20160714_youth_jobs_transcript

Summer jobs programs for young people have experienced a resurgence of interest and investment since the Great Recession, driven by concerns about high youth unemployment rates, particularly among low-income, black, and Hispanic youth. 

Summer jobs programs typically last five to seven weeks and provide work opportunities to teens and young adults who otherwise might struggle to find jobs. They offer a paycheck, employment experiences, and other organized activities in the service of multiple goals: increasing participants’ income, developing young people’s skills and networks to improve their labor market prospects, and offering constructive activities to promote positive behavior. Most young people are placed in subsidized positions in the public and nonprofit sectors, although most cities also secure unsubsidized and private-sector placements, which typically come with higher skill and work-readiness requirements. Recent research finds that summer jobs programs have positive effects: reducing violence, incarceration, and mortality and improving academic outcomes.

But a strong program does not automatically follow from good intentions. Program design and implementation carry the day and determine the results. Moreover, research has not yet linked summer jobs programs to improved employment outcomes; evaluations to date are silent on effective program design; and, in the absence of agreed-upon standards and best practices, there is no guarantee of quality.

This paper is written to help clarify what is known about summer jobs programs and to provide information and guidance to city leaders, policymakers, and funders as they consider supporting larger and better summer efforts. Many jurisdictions are rebuilding their summer programs after a long hiatus that followed the end of dedicated federal funding in the late 1990s. Summer jobs programs are complex endeavors to design and deliver. Local leaders and administrators make a multitude of choices about program design, implementation, and funding, and these choices have a direct impact on quality and results. It is an opportune moment to assess the knowledge base and gaps about the operations and impacts of summer jobs programs.

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Editor's Note: This piece originally appeared on Lawfare.

The United States began to use drones in Yemen in 2002 to kill individuals affiliated with al-Qaida in the Arabian Peninsula (AQAP) and its predecessor organizations and disrupt its operations there and abroad. Since then, over 200 strikes have killed over a thousand Yemenis, tens of children, and at least a handful of U.S. citizens – one of whom was a deliberate target. The program has drawn widespread condemnation from human rights organizations and some UN bodies, yet it remains in place because the administrations of George W. Bush and Barack Obama view it as a success, as both have publicly stated.

Criticism of the program often takes the form of debates about which legal regime is relevant to judging a state’s use of targeted killings, which critics call “extra-judicial executions” or simply “assassinations.” While dissent has been strongest in academic and human rights communities, some scholars have echoed the arguments made by states that the imperatives of self-defense permit states to carry out such killings as legitimate acts of war. The Lawfare consensus seems in favor of these strikes.

I share the views of the moral and legal dissenters and hesitate to move beyond those debates because I don’t want to suggest that I accept the program’s legality. 

But I do want to engage those who do view the program as working — after all, if the U.S. administration did not believe it was working, it wouldn’t need to justify it legally. But by what metrics should we consider judging its success?

Perhaps the most obvious metric is whether AQAP leaders are actually being killed and, even more, whether their deaths substantially disrupted the group’s activities in Yemen or its ability to pursue objectives outside of Yemen. For advocates of this metric, the program has been successful in the short term — individuals killed – even if the longer-term impact is less clear because new leaders seem to step in with regularity.

Yet the success in taking out AQAP’s leadership is overstated. The numbers of AQAP members and supporters officially reported as killed are questionable, and probably grossly exaggerated. This is because the U.S. administration considers all adult males in the vicinity of the strikes to be combatants, not civilians, unless their civilian status can be established subsequently. Full investigations are neither desirable nor pragmatic for the U.S. government – particularly now that Yemen is the site of a civil and regional war. Even more troubling is that at times the U.S. may not even be certain of its primary targets. It frequently uses language that is so conditional that there seems to be more than a bit of guessing about the identities of those being targeted.

But I would like to focus on different metric: the longer-term impact of the drone strikes on the legitimacy and attractiveness of al-Qaida’s message in Yemen and its ability to recruit among Yemenis themselves. Drone strikes are widely reported in local media and online and are a regular topic of discussion at weekly qat chewing sessions across the country. Cell phone calls spike after drone strikes, which are also widely reported on Twitter and Facebook. The strikes are wildly unpopular, with attitudes toward the United States increasingly negative. An Arab Barometer survey carried out in 2007 found that 73.5 percent of Yemenis believed that U.S. involvement in the region justified attacks on Americans everywhere.

The narrative that the West, and especially the United States, fears the Muslim world is powerful and pervasive in the region. The U.S. intervenes regularly in regional politics and is a steadfast ally of Israel. It supports Saudi Arabia and numerous other authoritarian regimes that allow it to establish permanent U.S. military bases on Arab land. It cares more about oil and Israel than it does about the hundreds of millions in the region suffering under repressive regimes and lacking the most basic human securities. These ideas about the American role in Middle East affairs – many of them true – are among those in wide circulation in the region.

Al-Qaida has since 1998 advanced the argument that Muslims need to take up arms against the United States and its allied regimes in the region. Yet al-Qaida’s message largely fell on deaf ears in Yemen for many years. Yes, it did attract some followers, mostly those disappointed to have missed the chance to fight as mujahidin in Afghanistan. But al-Qaida’s narrative of attacking the foreign enemy at home did not resonate widely. The movement remained isolated for many years, garnering only limited sympathy from the local communities in which they sought refuge. 

 The dual effect of U.S. acceleration in drone strikes since 2010 and of their continued use during the “transitional” period that was intended to usher in more accountable governance has shown Yemenis how consistently their leaders will cede sovereignty and citizens’ security to the United States. While Yemenis may recognize that AQAP does target the United States, the hundreds of drone strikes are viewed as an excessive response. The weak sovereignty of the Yemeni state is then treated as the “problem” that has allowed AQAP to expand, even as state sovereignty has been directly undermined by U.S. policy – both under President Ali Abdullah Salih and during the transition. American “security” is placed above Yemeni security, with Yemeni sovereignty violated repeatedly in service of that cause. Regardless of what those in Washington view as valid and legitimate responses to “terrorist” threats, the reality for Yemenis is that the United States uses drone strikes regularly to run roughshod over Yemeni sovereignty in an effort to stop a handful of attacks – most of them failed – against U.S. targets. The fact that corrupt Yemeni leaders consent to the attacks makes little difference to public opinion.

Regardless of what those in Washington view as valid and legitimate responses to “terrorist” threats, the reality for Yemenis is that the United States uses drone strikes regularly to run roughshod over Yemeni sovereignty in an effort to stop a handful of attacks – most of them failed – against U.S. targets.

The United States cut aid to Yemen in 1990 when the newly united Yemeni state, which had just rotated into the Arab seat on the UN Security Council, voted against authorization for a U.S.-led coalition to reverse the Iraqi invasion of Kuwait. Yemen suffered a tremendous economic blow, as the United States joined Kuwait and Saudi Arabia in unilaterally severing aid to what was then and still is the poorest Arab nation. But with the rise of jihadi activism on the Arabian Peninsula over the next decade, and particularly after the bombing of USS Cole in 2000, Salih welcomed the return of U.S. aid to Yemen. This included a strong security dimension as the United States began tracking those suspected of involvement in the Cole attacks and other al-Qaida activities. Conspicuous caravans of FBI agents became a topic of local conversations, so the return of a U.S. presence in Yemen was also more visible than it had been previously. Salih claimed to have had advance knowledge of every drone strike.

Saudi Arabia has meddled in Yemen at least since the fall of the northern Mutawakkilite monarchy in the late 1960s. The Saudi intervention that began with air strikes in March of this year and escalated to ground troops is thus only the latest — and most egregious — of the kingdom’s efforts to affect Yemen politics. This background is necessary to understand that if Yemen is a “failed state,” despite scholarly protestations otherwise, it is at least in part due to decades of external actors violating Yemeni sovereignty with near impunity. The drone program, like the Saudi-led war, is merely a recent and overt example.

I lived in Yemen for several years spread over the period from 1994-1999. During that time, the optimism about the democratic opening of 1990 gave way to increasing frustrations as Salih solidified his control over united Yemen. He defeated the southern leadership in the 1994 war and curtailed the freedoms and pluralism that marked the early unification period, but open public debate has always been vibrant. Travel throughout Yemen was easy at that time, the only obstacle being the need to hire an all-terrain vehicle and driver who knew the many poorly marked roads.

The Yemenis I met cut across social classes and regions, but were overwhelmingly welcoming and friendly toward Americans. In my research on Islamist political parties in Yemen and Jordan, I talked to hundreds of self-described Islamists. I spoke to people in the larger cities, the smaller towns, and in rural areas. We spent long hours talking about Islam and debating the contemporary political problems facing Yemen, the United States, and the world. In 1995 we spoke extensively about race and class in America as Yemenis watched the O.J. Simpson trial on CNN International. I often marveled at the knowledge Yemenis had of the U.S. political system; I wondered if most Americans had comparable knowledge of any other country at all. I was welcomed into homes and shared holidays with families.

What strikes me now is how most Islamists saw jihadi groups as having no place in Yemeni politics. There were jihadis in Yemen, of course, primarily the “Afghan Arabs” who had returned from fighting abroad in Afghanistan and other theaters of jihad and faced difficulties reassimilating. Islamists donning mustaches complained about Taliban proclamations that adult male Muslims must sport a beard at least a fist long. They also complained of the Saudi-sponsored “scientific institutes” that taught the super-conservative Wahhabi take on Islam. Salih had even enjoined these extremists to launch deadly attacks against Southern socialists in the first years after unification. Most of the individuals influenced by these trends eventually found their way into al-Qaida circles.

But they were relatively few. Al-Qaida found little success in attracting Yemenis who were not already drawn to jihadi ideas. The al-Qaida recruiting pitch of attacking foreign powers inside of Yemen simply rang hollow. Even the 2000 attack upon USS Cole — a warship docked in Aden — was not widely viewed as the legitimate targeting of a foreign military power intervening in Yemeni politics. Al-Qaida had to resort to extremist tactics precisely because its ideas did not attract a following significant enough to spark a popular mobilization.

For al-Qaida, the drone program is a gift from the heavens. Its recruiting narrative exploits common misperceptions of American omnipotence, offering an alternative route to justice and empowerment. Regardless of American perceptions about the legitimacy or efficacy of the attacks, what Yemeni could now deny that the United States is waging an undeclared war on Yemen?

Most recently, this narrative of direct U.S. intervention has been further substantiated by U.S. material and intelligence support for the Saudi-led military campaign aimed at the return to power of the unpopular and exiled-President Abed Rabbo Mansour Hadi. Photographs of spent U.S.-made cluster bombs are widely circulated. Nor have drone attacks ceased; alongside the often indiscriminate Saudi-led bombing, American drones continue their campaign of targeted assassination. 

One might think that the Saudi attacks would not help al-Qaida, but it is contributing to al-Qaida’s growth in Yemen. The indiscriminate targeting of the Saudi-led campaign undermines any sense of security, let alone Yemeni sovereignty. And AQAP-controlled areas like the port of Mukalla are not being targeted by Saudi or Gulf troops at all. The United States aims to take up the job of targeting AQAP while the Saudi-led (and U.S.-backed) forces focus on defeating the Houthis and restoring Hadi to power. But the overall situation is one in which those multiple interventions in Yemen are creating an environment in which al-Qaida is beginning to appeal in ways it never had before.

For al-Qaida, the drone program is a gift from the heavens. Its recruiting narrative exploits common misperceptions of American omnipotence, offering an alternative route to justice and empowerment.

For these reasons, the U.S. use of drones to kill even carefully identified AQAP leaders in Yemen is counterproductive: it gives resonance to the claims of the very group it seeks to destroy. It provides evidence that al-Qaida’s claims and strategies are justified and that Yemenis cannot count on the state to protect them from threats foreign and domestic.

U.S. officials have argued that the drone program has not been used as a recruiting device for al-Qaida. But it is hard to ignore the evidence to the contrary, from counterinsurgency experts who have worked for the U.S. government to Yemeni voices like Farea Muslimi.

It’s not just that drone strikes make al-Qaida recruiting easier, true as that probably is, but that they broaden the social space in which al-Qaida can function. America does not need to win the “hearts and minds” of Yemenis in the service of some grand U.S. project in the region. But if America wants to weaken al-Qaida in Yemen, it needs at a minimum to stop pursuing policies that are bound to enrage and embitter Yemenis who might otherwise be neutral. 

There is an old saying that when the only tool you have is a hammer, everything starts to look like a nail. The U.S. military — let alone its drones — is not the only tool on which the United States can rely. But when the measure of success is as narrow as the killing of a specific person, the tool gets used with increasing frequency. Indeed, drone strikes have significantly expanded under the Obama administration.

It is crucial to see the bigger picture, the one in which long-time Yemeni friends tell me of growing anti-U.S. sentiment where there was previously very little. Public opinion toward America has clearly deteriorated over the past decade, and to reverse it may take much longer. But the use of drones to kill people deemed enemies of the United States, along with the Saudi-led war against the Houthis, is expanding the spaces in which al-Qaida is able to function.  

A key objective of the United Nations Development Programme (UNDP) is to assist its member countries in meeting the Millennium Development Goals (MDGs). UNDP pursues this objective in various ways, including through analysis and advice to governments on the progress towards the MDGs (such as support for the preparation and monitoring Poverty Reduction Strategies, or PRSs, in poor countries), assistance for capacity building, and financial and technical support for the preparation and implementation of development programs.

The challenge of achieving the MDGs remains daunting in many countries, including Tajikistan. To do so will require that all development partners, i.e., the government, civil society, private business and donors, make every effort to scale up successful development interventions. Scaling up refers to “expanding, adapting and sustaining successful policies, programs and projects on different places and over time to reach a greater number of people.” Interventions that are successful as pilots but are not scaled up will create localized benefits for a small number of beneficiaries, but they will fail to contribute significantly to close the MDG gap.

This paper aims to assess whether and how well UNDP is supporting scaling up in its development programs in Tajikistan. While the principal purpose of this assessment was to assist the UNDP country program director and his team in Tajikistan in their scaling up efforts, it also contributes to the overall growing body of evidence on the scaling up of development interventions worldwide.

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There are now more than 335 Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) in 47 states, DC, and Puerto Rico. Early results show that most Medicare ACOs are succeeding at meeting their quality benchmarks, but only about a quarter of MSSP participants have been able to reduce their spending enough below projected financial targets to qualify for shared savings. While these results are encouraging, especially given the financial and practice transformation necessary to succeed as an ACO, they also suggest that more work is needed from both CMS and the providers to ensure continued sustainability of the MSSP ACOs.

Given that the first three year cycle of MSSP ends in 2015 and more providers will likely be entering the MSSP in the coming years , the Centers for Medicare and Medicaid Services (CMS) has indicated that they intend to release a Notice of Proposed Rulemaking (NPRM) that will establish the rule for participation in the Medicare ACO program. In anticipation of these coming changes, the Engelberg Center for Health Care Reform released an issue brief that identifies the "Top Eight ACO Challenges" to encourage further discussion and considerations for ensuring the continued success of ACOs. These potential policy alternatives build on discussions with ACO Learning Network members and other related stakeholders implementing accountable care across the country and include the following issues.

These issues, and many others, will be a focus of the discussions at the upcoming Fifth National ACO Summit later this week.

Top Eight Medicare ACO Challenges

1. Make Technical Adjustments to Benchmarks and Payments
In order for ACOs to qualify for shared savings, they must be able to hold spending below a financial benchmark set using historical spending patterns and meet a certain threshold of person and population-level quality metrics. A number of issues should be considered that affect the ACO’s chances of being able to attain shared savings and have more predictability about their performance: benchmark calculation methodology, how to adjust for regional variation in performance, and risk adjustment.

2. Transition to More Person-Based Payments
The ultimate goal of an ACO is to improve quality at the patient and population level and control the growth of health care costs. In order to successfully achieve this mission, ACOs must over time make a transition to payments that involve the assumption of more risk by the provider organization with a reward for better health outcomes for groups of patients. ACOs must have a clear transition path for increasing accountability and assumption of more risk for patient health outcomes.

3. Increase Beneficiary Engagement
Patients can play a critical role in helping to achieve the goals of an ACO. Health outcomes are determined by whether patients follow prescribed therapies. Increasing beneficiary engagement holds the potential to make patients more activated members of the ACO who can contribute to its success. A number of issues should be considered to improve beneficiary engagement, including adjusting attribution methods, creating more incentives for patients to seek care within the ACO, and finding opportunities to activate patients as part of the care team.

4. Enhance and Improve Alignment of Performance Measures
A central tenet of Medicare ACOs is delivering high quality health care as determined by performance on 33 measures established by CMS. ACOs must meet performance benchmarks in order to be eligible for shared savings, ensuring that these organizations are delivering high value, rather than simply cheaper, care. A number of barriers exist to achieving better performance measurement, including administrative burdens, lack of measure alignment among payers, lack of rewards for quality improvement, and concerns about measure selection.

5. Enable Better and More Consistent Supporting Data
In order to succeed as an ACO, organizations must be able to effectively collect, interpret, and use clinical and claims data to transform care of their patients. ACOs need to adopt new health IT systems and other technologies in order to collect and use the growing amount of data. ACOs currently struggle with reconciling data between different sources, dealing with patients who opt out of data sharing, lack of timeliness for receiving data, difficulty of tracking patients through the health system, and delays in performance feedback.

6. Link to Additional Value-Based Payment Reforms
ACOs are just one of many payment reforms that health care organizations across the country are implementing to improve quality and reduce costs. Aligning the vision and components of these other initiatives with ACO reforms has the potential to reinforce the shared goals and fundamentally change the health system. However, there are barriers to achieving this alignment such as lacks of linkages to bundled payments and other new payment models, multi-payer ACOs with different payment systems, and inability for organizations to participate in multiple CMS payment innovations.

7. Develop Bonus Payments and Other Incentives to Participate
In order to effectively transform clinical practice, ACOs must create or procure significant financial and human capital, as well as transform their information technology and delivery infrastructure. A recent survey estimates the average start-up cost for creating an ACO to be $2 million, with some ACOs investing significantly more in their first few years. Many ACOs, especially smaller ones, struggle to find sufficient start-up capital, are uncertain if they can assume the level of risk required for an ACO, and need significant staff and clinical change to effectively transform care.

8. Support Clinical Transformation
Becoming and succeeding as an ACO is a vast undertaking that requires immediately beginning to transform practice, finance, and operations. However, many providers, particularly those that are less experienced at systemic practice transformation, need more support in undertaking clinical transformation.

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• Issue Brief: Improving the Medicare ACO Program

Contributors: Alice M. Rivlin and Christine Dang-Vu

Recent data suggest that Accountable Care Organizations (ACOs) are improving important aspects of care and some are achieving early cost savings, but there is a long way to go. Not all ACOs will be successful at meeting the quality and cost aims of accountable care. The private sector has to date allowed more flexibility in terms of varying risk arrangements—there are now over 250 accountable care arrangements with private payers in all parts of the country—with notable success in some cases, particularly in ACOs that have been able to move farther away from fee-for-service payments. Future growth of the Medicare ACO program will depend on providers having the incentives to become an ACO and the flexibility to assume different levels of risk, ranging from exclusively upside arrangements to partial or fully capitated payment models.

Given that the first three year cycle of Medicare ACOs ends in 2015 and more providers will be entering accountable care in the coming years, the Centers for Medicare and Medicaid Services (CMS) has indicated that they intend to release a Notice of Proposed Rulemaking (NPRM) affecting the Medicare ACO program.

In anticipation of these coming changes, the Engelberg Center for Health Care Reform has identified the "Top Eight ACO Challenges" that warrant further discussion and considerations for ensuring the continued success of ACOs across the country. To support that discussion, we also present some potential alternatives to current Medicare policies that address these concerns. These findings build on the experiences of the Engelberg Center’s ACO Learning Network members and other stakeholders implementing accountable care across the country.  In some cases, the alternatives might have short-term costs, but could also improve the predictability and feasibility of Medicare ACOs, potentially leading to bigger impacts on improving care and reducing costs over time.  In other cases, the alternatives could lead to more savings even in the short term. In every case, thoughtful discussion and debate about these issues will help lead to a more effective Medicare ACO program.

Top Eight ACO Challenges

1. Make technical adjustments to benchmarks and payments
2. Transition to more person-based payments
3. Increase beneficiary engagement
4. Enhance and improve alignment of performance measures
5. Enable better and more consistent supporting data
6. Link to additional value-based payment reforms
7. Develop bonus payments and other incentives to participate
8. Support clinical transformation

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• Issue Brief: Improving the Medicare ACO Program

Event Information

Seven years ago, New Zealand recognized that if its people did not have sufficient assets as they aged, they would either face economic stress in retirement or place pressure on the government for costly additional benefits, and thus the KiwiSaver program was born. Designed to help citizens build retirement security, it guides individuals with limited financial experience while also giving them complete control of their finances. Benefits of this national automatic enrollment retirement savings plan include a $1,000 kick-start, employer contributions, and an annual tax credit. New Zealand Since its inception in July 2007, KiwiSaver has been deemed a great success, with over half of the eligible population as members, and over 70 percent of 18-24 year olds participating. Although membership continues to grow, it is at a slower rate than that seen in previous years.

Could the success of KiwiSaver mean that a similar program – at either the national or state level – might work here? On July 8^th, Diana Crossan, former Retirement Commissioner for New Zealand, will offer her insights into the KiwiSaver program and its impact on New Zealand saving, retirement security, and financial literacy. Ben Harris and David John, deputy directors of the Retirement Security Project at Brookings, will reflect on the role such a program might play in the U.S.

Email international@aarp.org to RSVP »