The Central African Republic (CAR), a landlocked country roughly the size of Texas, has endured a nearly constant state of political crisis since its independence from France in 1960. In fact, in the post-colonial era, the CAR has experienced only 10 years of rule under a democratically elected leader, Ange-Félix Patassé, from 1993 to 2003. Four of the CAR’s past five presidents have been removed from power through unconstitutional means, and each of these transitions has been marred by political instability and violence. Fragile attempts to build democratic political institutions and establish the rule of law have been undermined by coups, mutinies, and further lawlessness, making cycles of violence tragically the norm in the CAR.

The country’s current crisis (2012–present) stems from political tensions and competition for power between the predominantly Muslim Séléka rebel coalition and the government of President Francois Bozizé, as well as unresolved grievances from the CAR’s last conflict (2006–2007). Since the Séléka’s overthrow of the government in March 2013 and concurrent occupation of large areas of the country, the conflict has evolved to encompass an ethno-religious dimension: So-called Christian defense militias named the anti-balaka emerged to counter the Séléka alliance, but in effect sought revenge against the CAR’s Muslim minority (about 15 percent of the population), including civilians. During a March 2014 trip to the Central African Republic, United Nations High Commissioner for Human Rights Navi Pillay remarked that “the inter-communal hatred remains at a terrifying level,” as reports of atrocities and pre-genocidal indicators continued to surface. Even today, horrific crimes against civilians are still being committed at a frightening frequency in one of the poorest countries in the world: The CAR has a per capita GNI of $588 and a ranking of 185 out of 187 on 2013’s United Nations Human Development Index.

Amid the escalating insecurity in 2013, African Union (AU), French, and European forces were deployed under the auspices of the African-led International Support Mission in Central Africa (MISCA) to disarm militant groups and protect civilians at a critical juncture in December, and their efforts contributed to the relative stabilization of the capital in early 2014. Meanwhile, in January 2014, Séléka leaders relinquished power to a transitional government led by former mayor of Bangui, Catherine Samba-Panza, who was then tasked with preparing for national elections and establishing security throughout the country. In September 2014, the United Nations incorporated the MISCA forces into the larger Multidimensional Integrated Stabilization Mission in the Central African Republic (MINUSCA) and then in 2015 extended and reinforced its presence through 2016, in response to the ongoing violence. Despite the international military intervention and efforts of the transitional authorities to address the pervasive insecurity, reprisal killings continue and mobile armed groups still freely attack particularly remote, rural areas in the central and western regions of the country. The unguarded, porous borders have also allowed rebel forces and criminal elements to flee into distant areas of neighboring countries, including Chad and South Sudan, in order to prepare their attacks and return to the CAR.

This paper will explore the origins of the complex emergency affecting the CAR, with a particular focus on the economic causes and potential economic strategies for its resolution. It will begin by providing an overview of the core issues at stake and enumerating the driving and sustaining factors perpetuating the violence. Then it will discuss the consequences of the conflict on the humanitarian, security, political, and economic landscape of the CAR. Finally, it will highlight strategies for addressing the underlying issues and persisting tensions in the CAR to begin building a durable peace, arguing that the national authorities and international partners adopt a holistic approach to peace building that prioritizes inclusive economic recovery given the economic roots of the crisis.

Download the full paper »

Editors' Note: It has perhaps never been more important to question the prevailing wisdom on the 2011 United States-led intervention in Libya, writes Shadi Hamid. Even with the benefits of hindsight, he argues, many of the criticisms of the intervention fall short. This post originally appeared on Vox.

Libya and the 2011 NATO intervention there have become synonymous with failure, disaster, and the Middle East being a "shit show" (to use President Obama’s colorful descriptor). It has perhaps never been more important to question this prevailing wisdom, because how we interpret Libya affects how we interpret Syria and, importantly, how we assess Obama’s foreign policy legacy.

Of course, Libya, as anyone can see, is a mess, and Americans are reasonably asking if the intervention was a mistake. But just because it’s reasonable doesn’t make it right.

Most criticisms of the intervention, even with the benefit of hindsight, fall short. It is certainly true that the intervention didn’t produce something resembling a stable democracy. This, however, was never the goal. The goal was to protect civilians and prevent a massacre.

Critics erroneously compare Libya today to any number of false ideals, but this is not the correct way to evaluate the success or failure of the intervention. To do that, we should compare Libya today to what Libya would have looked like if we hadn’t intervened. By that standard, the Libya intervention was successful: The country is better off today than it would have been had the international community allowed dictator Muammar Qaddafi to continue his rampage across the country.

Critics further assert that the intervention caused, created, or somehow led to civil war. In fact, the civil war had already started before the intervention began. As for today’s chaos, violence, and general instability, these are more plausibly tied not to the original intervention but to the international community’s failures after intervention.

The very fact that the Libya intervention and its legacy have been either distorted or misunderstood is itself evidence of a warped foreign policy discourse in the U.S., where anything short of success—in this case, Libya quickly becoming a stable, relatively democratic country—is viewed as a failure.

NATO intervened to protect civilians, not to set up a democracy

As stated in the U.N. Security Council resolution authorizing force in Libya, the goal of intervention was "to protect civilians and civilian populated areas under threat of attack." And this is what was achieved.

In February 2011, anti-Qaddafi demonstrations spread across the country. The regime responded to the nascent protest movement with lethal force, killing more than 100 people in the first few days, effectively sparking an armed rebellion. The rebels quickly lost momentum, however.

I still remember how I felt in those last days and hours as Qaddafi’s forces marched toward Benghazi. In a quite literal sense, every moment mattered, and the longer we waited, the greater the cost.

It was frightening to watch. I didn’t want to live in an America where we would stand by silently as a brutal dictator—using that distinct language of genocidaires—announced rather clearly his intentions to kill. In one speech, Qaddafi called protesters "cockroaches" and vowed to cleanse Libya "inch by inch, house by house, home by home, alleyway by alleyway."

Already, on the eve of intervention, the death toll was estimated at somewhere between 1,000 and 2,000. (This was when the international community’s tolerance for Arab Spring–related mass killings was still fairly low.)

As Obama’s advisers saw it, there were two options for military action: a no-fly zone (which, on its own, wouldn’t do much to stop Qaddafi’s tanks) or a broader resolution that would allow the U.S. and its allies to take further measures, including establishing what amounted to a floating no-drive zone around rebel forces. The president went with the latter option.

The NATO operation lasted about seven months, with an estimated death toll of around 8,000, apparently most of them combatants on both sides (although there is some lack of clarity on this, since the Libyan government doesn’t clearly define "revolutionaries" or "rebel supporters"). A Human Rights Watch investigation found that at least 72 civilians were killed as a result of the NATO air campaign, definitively contradicting speculative claims of mass casualties from the Qaddafi regime.

Claims of "mission creep" have become commonplace, most forcefully articulated by the Micah Zenko of the Council on Foreign Relations. Zenko may be right, but he asserts rather than explains why mission creep is always a bad thing. It may be that in some circumstances, the scope of a mission should be defined more broadly, rather than narrowly.

If anything, it was the Obama administration’s insistence of minimizing the mission—including the absurd claim that it would take "days, not weeks"—that was the problem from the very start. Zenko and others never make clear how civilians could have been protected as long as Qaddafi was waging war on them.

What Libya would look like today if NATO hadn’t intervened

It’s helpful to engage in a bit of counterfactual history here. As Niall Ferguson notes in his book Virtual Alternatives, "To understand how it actually was, we therefore need to understand how it actually wasn’t."

Applied to the Libyan context, this means that we’re not comparing Libya, during or after the intervention, with some imagined ideal of stable, functioning democracy. Rather, we would compare it with what we judge, to the best of our ability, the most likely alternative outcome would have been had the U.S. not intervened.

Here’s what we know: By March 19, 2011, when the NATO operation began, the death toll in Libya had risen rapidly to more than 1,000 in a relatively short amount of time, confirming Qaddafi’s longstanding reputation as someone who was willing to kill his countrymen (as well as others) in large numbers if that’s what his survival required.

There was no end in sight. After early rebel gains, Qaddafi had seized the advantage. Still, he was not in a position to deal a decisive blow to the opposition. (Nowhere in the Arab Spring era has one side in a military conflict been able to claim a clear victory, even with massive advantages in manpower, equipment, and regional backing.)

Any Libyan who had opted to take up arms was liable to be captured, arrested, or killed if Qaddafi "won," so the incentives to accept defeat were nonexistent, to say nothing of the understandable desire to not live under the rule of a brutal and maniacal strongman.

The most likely outcome, then, was a Syria-like situation of indefinite, intensifying violence. Even President Obama, who today seems unsure about the decision to intervene, acknowledged in an August 2014 interview with Thomas Friedman that "had we not intervened, it’s likely that Libya would be Syria...And so there would be more death, more disruption, more destruction."

What caused the current Libyan civil war?

Critics charge that the NATO intervention was responsible for or somehow caused Libya’s current state of chaos and instability. For instance, after leaving the Obama administration, Philip Gordon, the most senior U.S. official on the Middle East in 2013-'15, wrote: "In Iraq, the U.S. intervened and occupied, and the result was a costly disaster. In Libya, the U.S. intervened and did not occupy, and the result was a costly disaster. In Syria, the U.S. neither intervened nor occupied, and the result is a costly disaster."

The problem here is that U.S. intervention did not, in fact, result in a costly disaster, unless we are using the word "result" to simply connote that one thing happened after a previous thing. The NATO operation ended in October 2011. The current civil war in Libya began in May 2014—a full two and a half years later. The intervention and today’s violence are of course related, but this does not necessarily mean there is a causal relationship.

To argue that the current conflict in Libya is a result of the intervention, one would basically need to assume that the outbreak of civil war was inevitable, irrespective of anything that happened in the intervening 30 months.

This makes it all the more important to distinguish between the intervention itself and the international community’s subsequent failure—a failure that nearly all the relevant actors acknowledge—to plan and act for the day after and help Libyans rebuild their shattered country.

Such measures include sending training missions to help the Libyan army restructure itself (only in late 2013 did NATO provide a small team of advisers) or even sending multinational peacekeeping forces; expanding the United Nations Support Mission in Libya’s (UNSMIL) limited advisory role; and pressuring the Libyan government to consider alternatives to a dangerous and destabilizing political isolation law.

While perhaps less sexy, the U.S. and its allies could have also weighed in on institutional design and pushed back against Libya’s adoption, backed by UNSMIL, of one of world’s most counterproductive electoral systems—single non-transferable vote—along with an institutional bias favoring independents. This combination exacerbated tribal and regional divisions while making power sharing even more difficult.

Finally, the U.S. could have restrained its allies, particularly the Gulf States and Egypt, from excessive meddling in the lead-up to and early days of the 2014 civil war.

Yet Libya quickly tumbled off the American agenda. That’s not surprising, given that the Obama administration has always been suspicious of not just military entanglements but any kind of prolonged involvement—diplomatic, financial, or otherwise—in Middle East trouble spots. Libya "was farmed out to the working level," according to Dennis Ross, who served as a special assistant to President Obama until November 2011.

There was also an assumption that the Europeans would do more. This was more than just a hope; it was an organizing principle of Obama administration engagement abroad. Analysts Nina Hachigian and David Shorr have called it the "Responsibility Doctrine": a strategy of "prodding other influential nations…to help shoulder the burdens of fostering a stable, peaceful world order."

This may be the way the world should operate, but as a set of driving assumptions, this part of the Obama doctrine has proven to be wrong at best, and rather dangerous at worst.

We may not like it—and Obama certainly doesn’t—but even when the U.S. itself is not particularly involved in a given conflict, at the very least it is expected to set the agenda, convene partners, and drive international attention toward an issue that would otherwise be neglected in the morass of Middle East conflicts. The U.S., when it came to Libya, did not meet this minimal standard.

Even President Obama himself would eventually acknowledge the failure to stay engaged. As he put it to Friedman: "I think we [and] our European partners underestimated the need to come in full force if you’re going to do this."

Yet it is worth emphasizing that even with a civil war, ISIS’s capture of territory, and as many as three competing "governments," the destruction in Libya still does not come close to the level of death and destruction witnessed in Syria in the absence of intervention.

In other words, even this "worst-case scenario" falls well short of actual worst-case scenarios. According to the Libya Body Count, around 4,500 people have so far been killed over the course of 22 months of civil war.

In Syria, the death toll is about 100 times that, with more than 400,000 killed, according to the Syrian Center for Policy Research.

We’re all consequentialists now

For the reasons outlined above, Libya’s descent into civil conflict—and the resulting power vacuum, which extremist groups like ISIS eagerly filled—wasn’t inevitable. But let’s hypothesize for a moment that it was. Would that undermine support for the original intervention?

The Iraq War, to cite the most obvious example, wasn’t wrong because it led to chaos, instability, and civil war in the country. It was wrong because the decision to intervene in the first place was not justified, being based as it was on faulty premises regarding weapons of mass destruction.

If Iraq had quickly turned out "well" and become a relatively stable, flawed, yet functioning democracy, would that have retroactively justified an unjustified war? Presumably not, even though we would all be happy that Iraq was on a promising path.

The near reverse holds true for Libya. The justness of military intervention in March 2011 cannot be undone or negated retroactively. This is not the way choice or morality operates (imagine applying this standard to your personal life). This may suggest a broader philosophical divergence: Obama, according to one of his aides, is a "consequentialist."

I suspect that this, perhaps more than narrower questions of military intervention, drives at least some of the revisionism over Libya’s legacy. If we were consequentialists, it would be nearly impossible to act anywhere without some sort of preordained guarantee that a conflict area—which likely hadn’t been "stable" for years or decades—could all of a sudden stabilize.

Was the rightness of stopping the Rwandan genocide dependent on whether Rwanda could realistically become a stable democracy after the genocide was stopped? And how could policymakers make that determination, when the stabilization of any post-conflict situation is dependent, in part, not just on factual assessments but on always uncertain questions of the international community’s political will—something that is up to politicians—in committing the necessary time, attention, and resources to helping shattered countries rebuild themselves?

The idea that Libya, because it had oil and a relatively small population, would have been a relatively easy case was an odd one. Qaddafi had made sure, well in advance, that a Libya without him would be woefully unprepared to reconstruct itself.

For more than four decades, he did everything in his power to preempt any civil society organizations or real, autonomous institutions from emerging. Paranoid about competing centers of influence, Qaddafi reduced the Libyan army to a personal fiefdom. Unlike other Arab autocracies, the state and the leader were inseparable.

To think that Libya wouldn’t have encountered at least some major instability over the course of transition from one-person rule to an uncertain "something else" is to have a view of political development completely detached from both history and reality.

A distorted foreign policy discourse

The way we remember Libya suggests that the way we talk about America’s role in the world has changed, and not for the better. Americans are probably more likely to consider the Libya intervention a failure because the U.S. was at the forefront of the NATO operation. So any subsequent descent into conflict, presumably, says something about our failure, which is something we’d rather not think about.

Outside of the foreign policy community, politicians are usually criticized for what they do abroad, rather than what they don’t do. As former Secretary of Defense Robert Gates put it, "[Qaddafi] was not a threat to us anywhere. He was a threat to his own people, and that was about it." If the U.S had decided against intervention, Libya would have likely reverted to some noxious combination of dictatorship and insurgency. But we could have shirked responsibility (a sort of inverse "pottery barn" principle—if you didn’t break it, you don’t have to fix it). We could have claimed to have "done no harm," even though harm, of course, would have been done.

There was a time when the United States seemed to have a perpetual bias toward action. The instinct of leaders, more often than not, was to act militarily even in relatively small conflicts that were remote from American national security interests. Our country’s tragic experience in Iraq changed that. Inaction came to be seen as a virtue. And, to be sure, inaction is sometimes virtuous. Libya, though, was not one of those times.

Baltimore provides a prime example of how metropolitan areas around the nation are turning to clean, green industries as a source of vibrant, sustainable growth. Expert Jennifer Vey outlines how such communities can identify their assets and capitalize on them to revitalize their economies.

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• Baltimore as a Case Study in Metro Economic Recovery

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• @ Brookings Podcast: Baltimore as a Case Study in Metro Economic Recovery

Editor’s note: This post is adapted from a forthcoming full-length case study; the second in a series from the Engelberg Center’s Merkin Initiative on Physician Payment Reform and Clinical Leadership designed to support clinician leadership of health care delivery, payment, and financing reform. The case study will be presented during the Merkin Initiative’s “MEDTalk” event on July 9 from 10:30 AM to 12:30 PM EDT, featuring live story-telling and knowledge-sharing from patients, providers, and policymakers.

Oncology practices and hospitals across the nation struggle with providing sustainable, comprehensive, and coordinated cancer care. Clinical leaders with strategies and models to improve the quality and value of health care often don’t know how to navigate the landscape of payment and delivery reform options to sustain their innovations.

We use a case study approach to investigate and tell the story of the New Mexico Cancer Center (NMCC), an independent cancer center that is experimenting with innovative ways to improve patient-centered oncology care. We identify challenges for creating sustainable and supportive payments models, and we share the broader strategic and policy lessons for adopting alternative payment models.

The Clinical Scenario: Living With Cancer

Vicky Bolton, a 58-year-old full-time medical legal coordinator from Albuquerque, has stage 4 adenocarcinoma lung cancer. She started chemotherapy in 2003 and has consistently received treatments over the last 11 years. Vicky is one of 13 million Americans currently living with cancer, with more than 1.6 million new diagnoses added each year.

Although Vicky’s condition is currently stable, she is at high risk for venous thrombosis (blood clots), life-threatening infections, and other complications, which put her at high risk for repeated hospitalizations. In the past six months, she has taken advantage of “after hours” care on three occasions as an outpatient at NMCC. Fortunately, each of her providers and services — oncology, radiation therapy, labs, x-rays, and internal medicine — are centralized in a single location at NMCC, reducing the need for emergency room (ER) visits or hospitalizations for these episodes.

The Challenge: Controlling Spending While Improving Patient-Centered Care

Cancer is the second leading cause of death in the U.S. Forty-one percent of Americans will be diagnosed with cancer during their lives. Cancer care is also expensive, accounting for $125 billion of total health care spending annually. In 2011, Medicare alone spent nearly $35 billion in fee-for-service (FFS) payments for cancer care, representing 9 percent of all Medicare FFS payments.

The high costs of cancer care are driven by issues that plague the entire health system: uncoordinated care delivery, duplication of services, fragmentation, and volume-based payments. A common impact of these drivers in oncology is the use of the ER to relieve symptoms associated with adverse effects of chemotherapy or other treatments that can also result in hospitalization.

For example, research shows that the most common reasons for cancer patient ER admissions are pain, respiratory distress, nausea, and vomiting. More than half of the ER visits occurred on weekends or in the evening, and over 60 percent resulted in hospital admission. This suggests that if a patient’s symptoms could be managed at home or in the community, costly hospital admissions could be avoided. ER visits, where patients are exposed to germs and infections as they wait — often hours — to be admitted, can have catastrophic outcomes for patients that are actively in treatment since they have weakened immune systems and are more prone to infections.

In addition to the inherent issues with fee-for-service (FFS) payments — with payments incentivizing volume of procedures rather than the value of care delivered — the current payment system further exacerbates problems: If a practice provides higher-value care to patients at a lower cost to the overall system (that is, they perform fewer services and have lower revenue), the financial winner is the payer who reimburses fewer services, not the practice (which merely has less revenue). This combination of the misaligned incentives of FFS and the lack of financial benefit for improving care while reducing costs means that many practices simply cannot afford to make the transformations needed without other funding mechanisms.

The Real World: How Has An Independent Cancer Center Responded To These Challenges?

NMCC delivers care to roughly 2,700 patients and provides care to one in three New Mexicans with cancer. The changes that the center has made have focused on reducing the impact of fragmentation of care on their patients (Table 1).

A key innovation was enhancing comprehensive after-hours and weekend care on site and creating a telephone and urgent care triage program to avoid expensive emergency room and inpatient care, which NMCC termed the COME HOME model.

As part of its redesign process in 2012, NMCC – along with six community oncology practices — secured a $20 million Center for Medicare and Medicaid Innovation (CMMI) Health Care Innovation Award (HCIA), for a three-year period. The award has an explicit aim of reducing ER visits by 50 percent and hospitalizations by 20 percent to justify the program costs.

Table 1: Care Redesign Elements Undertaken by NMCC

The Key Levers: How Can COME HOME Be Sustained?

On the heels of the Affordable Care Act (ACA) and numerous quality and payment focused initiatives in the private sector, health care organizations need to enhance the competitiveness and efficiency of their systems in the marketplace.

Alternative payment models (APMs) such as Accountable Care Organizations (ACOs), bundled payments, and patient-centered oncology medical homes (PCOMH) are just a few of the initiatives supported by public and private payers to align care redesign and payment reform and encourage continuous improvement. (Clinical pathways, a strategy recently embraced by WellPoint, offer PCOMH-like incentives to encourage adherence to practice guidelines, a strategy primarily geared to encourage higher-value chemotherapy practice.)

Broader or larger case-based payments may also provide stronger incentives to limit costs, to help assure that promising delivery reforms actually lead to cost reduction, but this exposes oncologists to greater levels of financial risk, as shown in Table 2. Consequently, implementing payment reforms that are viewed as feasible and desirable by both providers and payers is difficult.

Table 2: Comparison of Alternative Payment Models for Oncology

The Path Ahead: How Can These Models Assist NMCC?

NMCC currently receives approximately $70,000 per month from the CMMI grant and has not yet identified a clear strategy to sustain the delivery reforms in the COME HOME care model past the end of the grant (July 2015). As for payment reform options, NMCC has been unable to contract as part of a comprehensive ACO due to local health care market conditions.

Clinical pathways are geared primarily to guidelines and chemotherapy adherence, and are not designed to provide funding for after-hours care or triage programs that are intended to achieve offsetting savings through avoiding costly complications. Possible remaining options include:

• PCOMH: Using the data it gathers, NMCC intends to quantify the additional costs the COME HOME model requires, and the savings that it achieves. Based on that estimate, NMCC could suggest a per-member per-month (PMPM) payment from a private insurer to cover the costs of providing higher quality care. To encourage participation, NMCC could also enter into a risk-sharing agreement, in which overall costs of inpatient care and ER visits would be compared against a target. The PMPM payment could be at-risk if the targets are not achieved after a certain period of time.

• Bundled Payments: NMCC could potentially use the medical home approach with risk sharing (described above) as a first, interim step toward a bundled payment system, NMCC’s long-term preferred model. Computing actuarially sound expected costs for the bundled payments would require merging claims data with clinical data (for example, ICD-9 codes fail to distinguish between subtypes of breast cancer that have radically different treatments). A bundled payment pilot might be performed for high volume cancers, such as breast and lung.

Lessons Learned

The experience of innovative pioneers like NMCC can shed some light on potential barriers to conceptualizing and implementing sustainable clinical redesign. The lessons learned have been sorted into three main categories: relationships with payers and networks, payment model selection, and data collection and quality improvement considerations.

Relationships with payers and networks. Though counterintuitive, merely demonstrating significant value from care design, perhaps from lower utilization of inpatient and emergency department utilization, does not automatically create a financial pathway for sustainable delivery reform. To do so, innovative providers should consider involving lead payer partners early on to help identify end-points of interest to payers and potential payment strategies that may emerge later.

Providing support for health care delivery reforms requires new activities by payers towards aligning their payments with value, rather than volume and intensity of services. However, fragmented health care markets face the challenge of the “free rider” problem: payers may be unwilling to shoulder delivery transformation costs that may benefit other payers’ clients while they wait for CMS or others to make the financial investment, pay for the program evaluation, and enact policy change). Other challenges include payer inertia and long lag times between care redesign and subsequent data demonstrating results.

Large ACOs and other integrated payer-provider plans, including those large enough to form Medicare Advantage plans, are moving forward on negotiating payment and delivery reforms. This may be more difficult for innovative, smaller practices, even if they can provide higher-value clinical services. In turn, this may have anti-competitive consequences, such as discouraging delivery innovation that leads to “demand destruction” of high-cost hospital-based services. Private and public payers should be particularly interested in developing models that enable smaller, specialized providers like oncology practices to undertake key delivery reforms.

Sustainable Payment Model Selection. While substantial attention has been paid to primary care focused APMs, specialty-focused APMs are needed for practices like NMCC. Their development should be a high priority for public and private payers. Clinical transformation grants, such as those offered by CMMI, should include clear pathways for transitioning to APMs if initial cost savings targets or projections are met. Otherwise, delivery system innovations are at high risk of failure despite evidence of improved value.

Data Collection and Quality Improvement Considerations. Timely sharing of actionable information from claims and other administrative data remains a major challenge, with complex and varied procedures for obtaining claims from payers; smaller practices are particularly challenged in interpreting the claims data. Some states, such as Maryland, Massachusetts, Vermont, and Colorado (among others) are proceeding with creating all-payer claims databases. (Maryland, for example, offers almost instantaneous provider feedback from claims through their CRISP database.)

Others, such as Minnesota, are using “distributed” approaches in which multiple payers and systems produce measures in consistent ways. As NMCC’s early efforts illustrate, practices can produce more clinically sophisticated performance measures. Strategies to achieve consistent methods for sharing key data on cost and quality need to be expanded to encourage quality improvement and payment reform.

Critics of the nation's retirement system regularly complain that the system is in crisis. Too many private companies fail to offer their employees a retirement plan. Many employees who are covered by a plan fail to make contributions to it. Those who do make contributions may contribute too little or invest their savings unwisely. The end result: Many of us will reach retirement age with miniscule pensions or too little savings to enjoy a comfortable old age.

The argument that our retirement system has gaping holes is well founded. The notion that it faces an imminent "crisis" is nonsense. If the system currently faces a crisis, it has faced the same one for the past 40 years. While elderly Americans have seen their incomes and living standards improve in recent decades, the median working-age family has experienced little improvement in its real income. Nonelderly families that depend solely on the earnings of breadwinners who have below-average schooling saw a drop in their incomes.

In recent research with Brookings colleagues, I tracked the real incomes of families headed by aged and nonaged Americans. In the 34 years ending in 2012, the median real income of working-age families climbed a little more than 2 percent (in other words, by less than one-tenth of a percentage point per year). The median real income of families headed by someone past 62 increased a little more than 40 percent. The numbers suggest our retirement system is doing a decent job improving the living standards of the aged. Unfortunately, the labor market is doing a much worse job boosting the living standards of middle-class wage earners.

Critics of the retirement system might worry that it succeeds in protecting the incomes of the middle class elderly but fails to protect the incomes of the poor -- a concern not supported by the evidence. Income inequality has gone up among the elderly as it has among the nonelderly. But older low-income Americans have fared much better than low-income working-age adults. In the late 1950s, by far the highest poverty rate of any age group was that for people over 65. Even in the late 1980s, the elderly had a higher poverty rate than adults between 18-64. Since the middle of the last decade, however, the elderly have had the lowest poverty rate of any age group.

People who warn us of a retirement "crisis" are nonetheless correct in pointing to sizeable holes in the current system. Too few companies, especially small ones, offer their workers a retirement plan. According to recent government estimates, only about half of workers in companies with fewer than 100 employees are offered a retirement plan. Offer rates are higher in bigger companies and in government agencies, but about 30 percent of all employees are not offered any pension or retirement savings plan where they work. When retirement plans are offered, however, workers are very likely to participate in them -- even if they must make a voluntary contribution out of their pretax wages.

What is crucial for a retirement savings plan's success is automatic payroll withholding. Dollars that are withheld from workers' paychecks are harder for workers to spend on something other than retirement savings. A crucial improvement in our current system would be to require all employers to establish automatic payroll withholding for voluntary retirement savings in an IRA (individual retirement account). Companies that already offer a qualified pension or retirement savings plan should be exempt from any extra obligation.

The harshest critics of the current retirement system would go much further than this. Many want to bring back traditional retirement plans that guaranteed workers a specific monthly pension linked to their job tenure, final pay, and age at retirement. The advantages of such a plan for workers are that their employer is typically responsible for funding the plan and for ensuring that pensions are paid, regardless of the ups and downs of financial markets. A big disadvantage is that the promised benefits are not worth much if the worker's career with a company is cut short, either because of a layoff or quitting.

People who are nostalgic for old-fashioned pensions may be right that workers would prefer to be covered by such a plan, despite their disadvantages for short-tenure workers. I'm less persuaded that traditional pensions offer better protection to typical workers than modern 401(k)-type plans. Regardless of the pros and cons of the two kinds of plan, it is wildly unrealistic to think small employers or new employers will want to take on the risks and administrative burdens connected with an old-fashioned pension plan.

All U.S. workers are covered by a traditional, defined-benefit pension: it's called Social Security. It has worked well over the past four decades in protecting and even lifting the incomes of the retired elderly. It may not work as well in the future if benefits are cut substantially to keep the program solvent. Boosting workplace retirement savings is a sensible way to insure future retirees will have adequate incomes, even if Social Security benefits have to be trimmed. An essential first step to boosting savings is to require companies to put a retirement savings plan in every workplace.

Editor's note: This piece originally appeared in Real Clear Markets.