Much public focus is being given to a broader role for hospitals in improving the health of their communities. This focus parallels a growing interest in addressing the social determinants of health as well as health care policy reforms designed to increase the efficiency and quality of care while improving health outcomes.

This interest in the community role of hospitals has drawn attention to the federal legal standards and requirements for nonprofit hospitals seeking federal tax exemption. Tax-exempt hospitals are required to provide community benefits. And while financial assistance to patients unable to pay for care is a basic requirement of tax-exemption, IRS guidelines define the concept of community benefit to include a range of community health improvement efforts.

At the same time, the IRS draws a distinction between community health improvement spending–which it automatically considers a community benefit–and certain “community-building” activities where additional information is required in order to be compliant with IRS rules. In addition, community benefit obligations are included in the Affordable Care Act (ACA).

Specifically, the ACA requires nonprofit hospitals periodically to complete a community health needs assessment (CHNA), which means the hospital must conduct a review of health conditions in its community and develop a plan to address concerns. While these requirements are causing hospitals to look more closely at their role in the community, challenges remain. For instance, complex language in the rules can mean hospitals are unclear what activities and expenditures count as a “community benefit.” Hospitals must take additional steps in order to report community building as community health improvement.

These policies can discourage creative approaches. Moreover, transparency rules and competing hospital priorities can also weaken hospital-community partnerships. To encourage more effective partnerships in community investments by nonprofit hospitals:

• The IRS needs to clarify the relationship between community spending and the requirements of the CHNA. 
• There needs to be greater transparency in the implementation strategy phase of the CHNA. 
• The IRS needs to broaden the definition of community health improvement to encourage innovation and upstream investment by hospitals.

Download "Hospitals as Community Hubs: Integrating Community Benefit Spending, Community Health Needs Assessment, and Community Health Improvement" »

Downloads

• Download "Hospitals as Community Hubs: Integrating Community Benefit Spending, Community Health Needs Assessment, and Community Health Improvement"

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.

As the nation still struggles with high healthcare costs that consume larger and larger portions of patient budgets as well as government coffers, the search for ways to get costs under control continues. Total healthcare spending in the U.S. now represents almost 18 percent of our entire economy. One promising cost-savings approach is called “reference pricing,” where the insurer establishes a price ceiling on selected services (joint replacement, colonoscopy, lab tests, etc.). Often, this price cap is based on the average of the negotiated prices for providers in its network, and anything above the reference price has to be covered by the insured consumer.

A study published in JAMA Internal Medicine by James Robinson and colleagues analyzed grocery store Safeway’s experience with reference pricing for laboratory services such as such as a lipid panel, comprehensive metabolic panel or prostate-specific antigen test. Safeway’s non-union employees were given information on prices at all laboratories through a mobile digital platform and told what Safeway would cover. Patients who chose a lab charging above the payment limit were required to pay the full difference themselves.

Employers see this type of program as a way to incentivize employees to think through the price of services when making healthcare decisions. Employees enjoy savings when they switch to a provider whose negotiated price is below the reference price, whereas if they choose services above it, they are responsible for the additional cost.

Robinson’s results show substantial savings to both Safeway and to its covered employees from reference pricing. Compared to trends in prices paid by insurance enrollees not subject to the caps of reference pricing, costs paid per test went down almost 32 percent, with a total savings over three years of $2.57 million – patients saved $1.05 million in out-of-pocket costs and Safeway saved $1.7 million.

I wrote an accompanying editorial in JAMA Internal Medicine focusing on different types of consumer-driven approaches to obtain lower prices; I argue that approaches that make the job simpler for consumers are likely to be even more successful. There is some work involved for patients to make reference pricing work, and many may have little awareness of price differences across laboratories, especially differences between those in some physicians’ offices, which tend to be more expensive but also more convenient, and in large commercial laboratories. Safeway helped steer their employees with accessible information: they provided employees with a smartphone app to compare lab prices.

But high-deductible plans like Safeway’s that provide extensive price information to consumers often have only limited impact because of the complexity of shopping for each service involved in a course of treatment -- something close to impossible for inpatient care. In addition, high deductibles are typically met for most hospitalizations (which tend to be the very expensive), so those consumers are less incentivized to comparison shop.

Plans that have limited provider networks relieve the consumer of much complexity and steer them towards providers with lower costs. Rather than review extensive price information, the consumer can focus on whether the provider is in the network. Reference pricing is another approach that simplifies—is the price less than the reference price? What was striking about Robinson’s results is that reference pricing for laboratories was employed in a high-deductible plan, showing that the savings achieved—in excess of 30 percent compared to a control—were beyond what the high deductible had accomplished.

While promising, reference pricing cannot be applied to all medical services: it works best for standardized services and where variation in quality is less of a concern. It also can be applied only to services that are “shoppable,” which is only about one-third of privately-insured spending. Even if reference pricing expanded to a number of other medical services, other cost containment approaches, including other network strategies, are needed to successfully contain health spending and lower costs for non-shoppable medical services.

Editor's note: This piece originally appeared in JAMA.

Last week, world leaders agreed on an ambitious set of Sustainable Development Goals (SDGs) for 2030. Fully costed, the price tag for achieving these goals over the next 15 years will run into the trillions of dollar, however. The implication is that everyone in the world will have to contribute in one way or another—private businesses as well public sector agencies.

Volunteers seem to be the least recognized group of contributors, despite being the least-expensive component. They often play a crucial role in “the last mile” of program implementation. Volunteer service in support of the SDGs also enriches the lives of volunteers and helps to building the sense of global citizenship that is essential for global peace and well-being.

For the individuals involved, the core benefit of volunteer action comes from working outside of your culture. Making sandwiches for your children is not volunteer action. Making sandwiches at a shelter for the homeless is.

This concept of volunteer action, or service, was probably absent in primitive tribal communities and in early civilizations—such as Egypt—where slavery was embedded in the culture. It was certainly present, however, in the great religions that subsequently emerged and evolved, including Buddhism, Judaism, Christianity, and Islam. It is implicit in the messages that Pope Francis brought to the United States and the United Nations earlier this month.

Volunteer action took a great leap forward when President John F. Kennedy established the Peace Corps in 1961 for international service and President Lyndon B. Johnson created VISTA in 1965 for domestic service. The evolution since then has been interesting.

The Peace Corps grew quickly to almost 16,000 volunteers in the field in the mid-1960s, dropped to as low as 4,000 in the 1970s, and grew back slowly to around 8,000 in the early 1990s. It has been stuck at this level since then, despite campaign promises by Presidents Clinton, Bush, and Obama to double the number of serving volunteers.

Meanwhile, a bubbling universe of international volunteer programs emerged in the United States. University-sponsored, corporation-sponsored, NGO-sponsored, and for-profit programs are sending more than 50,000 Americans to foreign countries for short-term and long-term service every year. Inspired by the Peace Corps, other advanced countries also created their own international volunteer programs.

The evolution of government-supported volunteer programs domestically was quite different. In 1993, President Clinton established the Corporation for National and Community Service to manage a new AmeriCorps program along with VISTA and several other small pre-existing programs. AmeriCorps has grown rapidly to the point of having 75,000 volunteers today engaged in full-time, one-year service commitments. Officials from other countries—both advanced and developing—have also been coming here for 20 years to see how AmeriCorps works, before then starting similar domestic service programs in their countries.

Two forces are driving the volunteer movement globally. The first is budget constraints everywhere. In our modern societies, everybody wants to enjoy a good life, but we haven’t figured out how to get enough tax revenue to pay the teachers, health workers, engineers, and community organizers needed to achieve this happy outcome. We have, however, figured out how to mobilize volunteers to provide these services to the neediest.

The second force is an abstract concept combining civic duty and helping the less fortunate. As modern societies have become wealthier, this concept has become more powerful.

Two manifestations of these forces are especially relevant now.

The first is the role of volunteers that has been incorporated in the U.N. Sustainable Development Goals. Implementation is receiving more attention in the SDG process than it received in the preceding Millennium Development Goal process. The U.N has recognized that mobilizing volunteers effectively will be necessary to achieve every one of the SDGs. No government has a budget big enough to pay a living wage for all the hours of work that will be required to meet its own SDGs.

The other manifestation is a new debate in the United States about “national service.” Since the military draft was terminated in 1973, concern has slowly grown about having a military force that does not reflect the broad population. It is possible that the sense of national unity felt so strongly after World War II was related to the experience of so many men and women performing national service outside their culture. That kind of service was a social and civic glue that seems in short supply now.

The Aspen Institute’s “Franklin Project” aims to create a one-year national service commitment—either civilian or military—that becomes a valued part of growing up in America. It can help cure the divisiveness by taking us outside our culture and helping us appreciate others. It can be a better kind of glue.

Volunteer action across borders can also be a better kind of glue for the whole world. 

SDGs) for 2030. Fully costed, the price tag for achieving these goals over the next 15 years will run into the trillions of dollar, however. The implication is that everyone in the world will have to contribute in one way or another—private businesses as well public sector agencies.

Volunteers seem to be the least recognized group of contributors, despite being the least-expensive component. They often play a crucial role in “the last mile” of program implementation. Volunteer service in support of the SDGs also enriches the lives of volunteers and helps to building the sense of global citizenship that is essential for global peace and well-being.

For the individuals involved, the core benefit of volunteer action comes from working outside of your culture. Making sandwiches for your children is not volunteer action. Making sandwiches at a shelter for the homeless is.

This concept of volunteer action, or service, was probably absent in primitive tribal communities and in early civilizations—such as Egypt—where slavery was embedded in the culture. It was certainly present, however, in the great religions that subsequently emerged and evolved, including Buddhism, Judaism, Christianity, and Islam. It is implicit in the messages that Pope Francis brought to the United States and the United Nations earlier this month.

Volunteer action took a great leap forward when President John F. Kennedy established the Peace Corps in 1961 for international service and President Lyndon B. Johnson created VISTA in 1965 for domestic service. The evolution since then has been interesting.

The Peace Corps grew quickly to almost 16,000 volunteers in the field in the mid-1960s, dropped to as low as 4,000 in the 1970s, and grew back slowly to around 8,000 in the early 1990s. It has been stuck at this level since then, despite campaign promises by Presidents Clinton, Bush, and Obama to double the number of serving volunteers.

Meanwhile, a bubbling universe of international volunteer programs emerged in the United States. University-sponsored, corporation-sponsored, NGO-sponsored, and for-profit programs are sending more than 50,000 Americans to foreign countries for short-term and long-term service every year. Inspired by the Peace Corps, other advanced countries also created their own international volunteer programs.

The evolution of government-supported volunteer programs domestically was quite different. In 1993, President Clinton established the Corporation for National and Community Service to manage a new AmeriCorps program along with VISTA and several other small pre-existing programs. AmeriCorps has grown rapidly to the point of having 75,000 volunteers today engaged in full-time, one-year service commitments. Officials from other countries—both advanced and developing—have also been coming here for 20 years to see how AmeriCorps works, before then starting similar domestic service programs in their countries.

Two forces are driving the volunteer movement globally. The first is budget constraints everywhere. In our modern societies, everybody wants to enjoy a good life, but we haven’t figured out how to get enough tax revenue to pay the teachers, health workers, engineers, and community organizers needed to achieve this happy outcome. We have, however, figured out how to mobilize volunteers to provide these services to the neediest.

The second force is an abstract concept combining civic duty and helping the less fortunate. As modern societies have become wealthier, this concept has become more powerful.

Two manifestations of these forces are especially relevant now.

The first is the role of volunteers that has been incorporated in the U.N. Sustainable Development Goals. Implementation is receiving more attention in the SDG process than it received in the preceding Millennium Development Goal process. The U.N has recognized that mobilizing volunteers effectively will be necessary to achieve every one of the SDGs. No government has a budget big enough to pay a living wage for all the hours of work that will be required to meet its own SDGs.

The other manifestation is a new debate in the United States about “national service.” Since the military draft was terminated in 1973, concern has slowly grown about having a military force that does not reflect the broad population. It is possible that the sense of national unity felt so strongly after World War II was related to the experience of so many men and women performing national service outside their culture. That kind of service was a social and civic glue that seems in short supply now.

The Aspen Institute’s “Franklin Project” aims to create a one-year national service commitment—either civilian or military—that becomes a valued part of growing up in America. It can help cure the divisiveness by taking us outside our culture and helping us appreciate others. It can be a better kind of glue.

Volunteer action across borders can also be a better kind of glue for the whole world. 

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

Downloads

• Download the Original Letter

Once upon a time, long ago, the development industry was fixated on measuring aid from richer to poorer countries. They called it ODA, standing for Official Development Assistance. For decades this aid has been codified, reported, and tracked, mostly by the Development Assistance Committee of the Organisation for Economic Co-operation and Development (DAC/OECD), a club of advanced economies. In advance of the Spring Meetings of the IMF and World Bank, the DAC announced that ODA has risen by 6.9% over 2014 levels to 132 billion dollars, a record amount. Importantly, ODA increased even after stripping out funds spent on refugees.

The United Nations has established targets for ODA—like the famous 0.7 percent of national income—which have taken on legendary status as benchmarks of national generosity. Only six out of 28 DAC countries met this target last year: Denmark, Luxembourg, The Netherlands, Norway, Sweden and the United Kingdom.

Some institutions and lobby groups remain fixated on ODA, but many development actors now reject it as flawed. A major theme of the Spring Meetings is how to move beyond ODA and expand other forms of financing for development. ODA is, among other things, symptomatic of a charity perspective, rather than investment; inappropriate for South-South cooperation; and unable to capture the big new landscape of public-private links. What’s more, it is riddled with self-serving quirks like scoring numerous flows—the cost of university places in donor countries, and administrative costs of aid agencies—that never reach developing countries.

Perhaps the most telling weakness of ODA is that emerging powers like China and India see little merit (and arguably, some residual stigma) in this concept and, therefore, will not report on that basis to a club to which they do not belong. As their share of the world economy and their interactions with other “developing” countries continue to grow, this means ODA will inevitably start to represent an ever smaller share of official financing for development.

TOSSD stands for Total Official Support for Sustainable Development. The idea, still being fleshed out, is to have a universally accepted measure of the full array of public financial support for sustainable development. TOSSD should differ from ODA in at least three ways:

• First, it should take a developing country perspective rather than a donor country perspective. So it should cover the value of all funding for development that is officially supported, from pure grants to near-market loans and equity investments, as well as guarantees and insurance.
• Second, it should measure cross-border flows from all countries, not just the rich members of the OECD’s Development Assistance Committee.
• Third, it should include contributions to global public goods needed to support development, like U.N. peacekeeping and pandemic surveillance.

There are many complications behind any international attempt to define and track such a huge range of activities. Some are technical, but can probably be resolved with enough goodwill and professionalism. So, for example, we can debate how to establish whether and how official support to private investors changes their behaviour, delivering “additional” development results compared to a situation without that support. In the end, sensible solutions and workarounds will be found.

More difficult are a couple of politically sensitive challenges, which at the same time underlie the value of reaching consensus on a new measure. How far, for example, should the new measure recognise indirect spending on global public goods? Take for example public research on an AIDS vaccine that could lead to prevention of millions of deaths in developing countries. Right now, this would not count as ODA because the promotion of the economic development and welfare of developing countries is not its main objective.

We tend to think that consideration of globe-spanning benefits like these, which do not fit the simple mould of money crossing borders, is an essential feature of a new measure of development finance. However, it will need to be bounded sensibly, not least because of underlying suspicions that the countries that are today most likely to deploy such tools, and claim them as a large part of their distinctive contribution, are among the “old rich”—though that could change quickly. We suggest that spending on a defined list of global public goods should be included, perhaps those that support Agenda 2030, such as U.N. peacekeeping or a global research consortium like GAVI, the Vaccine Alliance.

A second potentially divisive issue, already alluded to, is how to value non-monetary flows, like technical assistance, and in a fair way across countries. We think it would be a powerful positive signal for international cooperation if even modest contributions by low- and middle-income countries are recognised, celebrated, and valued according to the contribution being made, not the cost of providing the assistance. The assistance provided by professionals from developing countries (think Cuban doctors) should be measured at the same prices as assistance provided by professionals from rich countries. Some form of purchasing power parity equivalence would need to be defined and used.

This is a hugely contentious question. Neither of the most obvious answers, the well-organised but globally unloved OECD and the legitimate but under-resourced U.N. secretariat, are likely to be acceptable without some changes. A preferred candidate has to have a sufficiently broad group of countries prepared to self-report on even a loose set of definitions in order to get momentum. At a minimum all the major economies of the world, for example members of the G-20, should be willing to participate. It should also have the technical capacity to help countries provide information in a consistent way.

The International Monetary Fund or World Bank could be candidates—most countries already report to them on a range of data, including financial flows. The Global Partnership for Effective Development Cooperation, with its membership of many development actors and technical support, could be another. Or a new group could be created in much the same way as the International Aid Transparency Initiative. This could even be a revamped Development Assistance Committee that operates with broader support in much the same way as the OECD’s tax work has many non-OECD members participating. What is important is that the guiding principle be to measure official cross-border financial resources that support the new universally-agreed Sustainable Development Goals, and to start now and learn by doing.  Such initiatives are too easily killed by subjecting them to endless external criticism that a perfect solution has not been found.

TOSSD may be one of the least attractive acronyms on offer today. Without disrespect to its OECD authors, it will anyway have to change to something that works for all the major stakeholders, and is not visibly invented in Paris and that also encourages players who are not strictly speaking “official,” like foundations, to sign up. We tend to favor a plainer, simpler wrapper like International Development Contributions (IDC), or Defined Development Contributions (DDC). 

Editors' Note: America has fallen behind its economic competitors—namely Russia and China—in Arctic resource and infrastructure investment. Charles Ebinger argues that the United States must better define its resource development policies and priorities in order to ensure U.S. leadership in the Arctic. This piece was originally published on Forbes. 

The recent decision by the United States to allow energy exploration drilling to re-commence in the Alaskan Arctic’s Chukchi Sea this summer is a welcome development. Here’s why: Federal waters in offshore Alaska are estimated to hold roughly 27 billion barrels of oil and 132 trillion cubic feet of natural gas, the vast majority of which is located in the Arctic. Experts believe that the Chukchi in particular, which holds more resources than any other undeveloped U.S. energy basin, may represent one of the world’s largest sources of untapped oil and gas.

Until now America has regrettably been on the sidelines of Arctic resource and infrastructure investment while our economic competitors—Russia and China included—have moved forward. This policy vacuum was highlighted in a recent National Petroleum Council (NPC) report to the U.S. Secretary of Energy in which I participated and which warned that if we effect no policy changes on an urgent basis we will not stay ahead of or even keep pace with our foreign rivals, remain globally competitive, or provide global leadership and influence in this critical region.

America is more energy self-sufficient than it has ever been

The report comes at a time when the U.S. has cut imports, drastically transforming our nation into the biggest producer of oil and natural gas by tapping huge reserves in shale rock formations across the country. As such, America is more energy self-sufficient than it has ever been. Even so, as evidenced by strong public support for Arctic offshore development in states ranging from Alaska to Iowa, South Carolina and New Hampshire, the American people recognize that we cannot rely solely on shale oil and gas to meet our energy needs.

To that point, as the NPC noted, if we fail to develop the enormous trove of reserves in Arctic waters off Alaska, the U.S. risks a renewed reliance on overseas energy in the future and will have missed a prime opportunity to keep domestic production high and imports and consumer costs low.

As President Obama rightly stated shortly after the Chukchi drilling plan was conditionally approved in May, “When it can be done safely and appropriately, U.S. production of oil and natural gas is important. I would rather us—with all the safeguards and standards that we have—be producing our oil and gas, rather than importing it, which is bad for our people, but is also potentially purchased from places that have much lower environmental standards than we do.

We have to take actions that allow exploration to commence now 

Indeed, given the long lead time necessary to develop resources in this region, the NPC study stressed that it is vital for the U.S. to take actions now that allow exploration in Alaskan Arctic waters to commence. In that regard, the recent approval for Arctic offshore drilling to occur this summer was a win for both Alaska, which is dependent on the petroleum industry to fund approximately 90 percent of its coffers, and the country at large, which leans on Alaskan energy to meet our daily needs, especially on the West Coast.

To ensure the long-term feasibility of offshore development in the region, Interior Department regulations for the U.S. Arctic in part must facilitate the use of proven technologies and also encourage innovation by providing the flexibility to incorporate future technologies as advances occur and their capacities are demonstrated. In addition, and all the more significant given our accession to chairmanship of the Arctic Council in May, U.S. policies governing natural resource development in the Arctic must be defined and streamlined.

Questions Washington has to answer if the U.S. wants to ensure its leadership in the Arctic

For example, what is the country’s official position on the development of oil, gas, mineral and fishery resources in the Arctic? Does it align with Alaska’s policies? How will resource development affect standards of living for those residing in the region?

In addition to resource development policies, other important questions must be addressed to ensure U.S. leadership in the Arctic. With Prudhoe Bay production in serious decline and the Trans-Alaska Pipeline System running at historically low throughput levels, how will the U.S. ensure access to new sources like Alaska’s Arctic offshore that can help all Americans? With just one heavy icebreaker in operation, and the cost of another tallying at least $700 million, what actions are we prepared to take to build a fleet capable of meeting the demands in an increasingly active region?

These are just a few of the questions and concerns that Washington, D.C. will have to answer soon if the U.S. stands a chance of catching up to or surpassing other nations that have so far leapt ahead to the front of the Arctic line. Will President Obama rise to the occasion and make the right decisions?

Cities across America are undergoing massive demographic change, and Philadelphia is no exception. Understanding this change, and effectively managing it, will be key to our national progress and prosperity in this decade and beyond.

A new report from the Brookings Institution, "The State of Metropolitan America," describes a nation that has grown larger, more diverse, more suburban, and more educated in the first decade of this century. These characteristics offer the potential for a tremendous advantage among industrialized nations as the global economy becomes more integrated and more competitive.

The Philadelphia region, for instance, is now home to 92 colleges and universities - more than the renowned concentration of higher education institutions in the Boston area. In our research on the demographic transformation of the nation, we refer to Philadelphia as a "skilled anchor" - one of 19 metro areas, including Baltimore, Rochester, N.Y., and Boston, that have made a transition from manufacturing and shipping to service-based economies. Medical and educational institutions have often driven this transformation, along with specialized manufacturing.

Skilled anchors face challenges, however, due to other trends. While 32 percent of Philadelphia area residents over the age of 25 hold bachelor's degrees, only 21 percent of residents of the city itself have been educated beyond high school.

That is cause for concern, especially as baby boomers begin to retire - most notably in the suburbs, where more than 40 percent of the residents are boomers and seniors. The young people who will take their place in the workforce are not completing college education at the same rate as their predecessors. This is problematic considering that median household income declined during the 2000s, and higher education is closely correlated with higher wages.

Meeting the region's future workforce challenges - that is, connecting residents to high-quality jobs in the education, medicine, life-sciences, and pharmaceutical sectors - will require education policies that prepare all children for successful postsecondary education, so they can build on the economic momentum of the retiring baby boomers.

As part of the national Achieving the Dream Initiative, several foundations are working together to help community colleges in Michigan, Ohio, and Indiana improve completion rates for minority and low-income students who are most at risk of dropping out and not getting the skills and credentials they need to succeed in the workforce.

Other demographic trends represent challenges as well as opportunities. The Philadelphia region's foreign-born population grew by 30 percent in the 2000s, albeit from a relatively small base. Efforts to incorporate immigrants into the mainstream of economic and civic life - such as Philadelphia's language-access policy, its one-stop education office, and the region's emerging Metropolitan Caucus - are all praiseworthy. But more is required.

At the same time, while solutions must be built from the ground up, the Philadelphia region can't go it alone. The federal government can't wait for megacities such as Philadelphia to work out the massive transformation under way by themselves. There are macro-level federal responses to these trends that could and should emanate from Washington.

Among them are comprehensive immigration reform that includes explicit means for improving the integration of new Americans into our society and economy; a revamping of transportation and housing policy that reduces energy-inefficient sprawl, accommodates seniors, and provides access to employment centers; programs to increase postsecondary education for our emerging workforce; and a redoubling of efforts to make work pay for working families, such as the Earned Income Tax Credit.

Over the past decade, between two recessions, Philadelphia has made much progress. Today, the region must capitalize on its hard-earned gains and address emerging challenges with similar conviction.