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.

Hillary Clinton isn’t often in the business of offering unsolicited advice to her Republican—or even Democratic—rivals in the presidential race. However, in a CNN interview with Alisyn Camerota on January 12, 2015, Hillary Clinton did just that. She did something quite taboo. She talked about the presidential transition.

Her comments did not flow from confidence that she would be elected president—a confidence she may indeed have. Her words came from experience, pragmatism and reality. They were words that did not simply reflect her own approach to a candidacy or a prospective administration. It was advice to everyone running for president about the right thing to do—not for themselves, but for the American public.

Clinton said:

I want to think hard—if I do get the nomination, right then and there—how we organize the White House, how we organize the Cabinet, what’s the legislative agenda. You know, the time between an election and an inauguration is short. You can’t wait. I mean, you can’t take anything for granted; you need to keep working as hard as you possibly can. But I think it’s important to start planning because we know what happens if you get behind in getting your agenda out, in getting your appointments made. You lose time, and you’re not doing the work the American people elected you to do.

Presidential candidates almost never speak of a transition until they are declared the president-elect in the late hours of the Tuesday following the first Monday in November. Candidates fear being accused of taking the election for granted, or “measuring the drapes.” They worry such planning will signal to voters an off-putting overconfidence.

Those fears may be legitimate, but acting on those concerns can be dangerous. If a voter believes a candidate should not prepare for a new administration until they are officially elected, that leaves the president-elect about 11 weeks to ready themselves for the busiest, most complicated, most important job in the world. In those 11 weeks, a president-elect would need to think not just about the 15 Cabinet secretaries who serve as the most visible political appointees in government, but literally hundreds and thousands of other posts. (One dirty little secret is that the President of the United States appoints over 3,000 people to his or her administration.)

Presidents have to think about the structure, order, and sequence of their legislative agenda. They need to communicate their intentions and plans to congressional leadership. They need to think about organizing a White House. The truth is from president to president, the White House looks the same from the outside, but is structured and functions dramatically differently on the inside. Presidents have myriad important decisions to make that will set the tone and agenda for the following four years and will affect every American in some way. Eleven weeks is not enough time. Clinton acknowledges this.

Clinton’s “bold” statement actually reflects a reality in American politics. As soon as an individual accepts his or her party’s presidential nomination, they are entitled to funding, office space, and government email and technology as part of the transition process. The Office of Personnel Management is involved, as is (of late) the Office of Presidential Personnel for the outgoing administration. The presidential transition is an essential part of democracy, policymaking, administration, and the continuity of government. Every four years, the government supports two transitions—one that comes to be and one that closes up shop.

In one way however, Hillary Clinton is entirely wrong. Waiting until you receive the nomination is too late to begin thinking about the transition. As I have written before, every presidential candidate should start thinking about a transition as soon as they announce their candidacy. They don’t need a full Cabinet chosen on Day 1 of the campaign, but they should designate one or two close advisers to organize for the process, begin considering names for posts, think through the types of policies to propose in the first 100 days, and begin what is one of the most complicated managerial tasks in the world.

Hillary Clinton is right “it is important to start planning,” and it’s also never too early to do so. I hope Clinton’s claim that one should start upon securing the nomination is a reflection of that fear of the “drape measuring” accusation. I hope she is planning her transition now. I hope Bernie Sanders and Ted Cruz and Donald Trump and John Kasich and everyone else is planning their transition right now. It’s essential. Clinton knows the challenges of setting up a White House and the complications that early disorganization can cause; she saw that dysfunction first hand in 1993. But most candidates have also worked in or around the White House or have been in politics long enough to know the importance of an effective transition. And candidates who haven’t, like Donald Trump and Carly Fiorina, should be more inclined to set up a transition early, as they have more managerial experience than anyone else in the race.

To this end, I have a modest proposal. It probably won’t happen. It’s likely one that candidates would fear, and it would likely only be effective if everyone is on board. Every current presidential candidate should sign a pledge committing to two things. First, by February 1, 2016, they will designate at least one staffer, adviser or confidante as a transition director.  Second, they will not publicly criticize another candidate—of either party—for having a transition staffer or team in place. Call it a “Transition Truce.” But the reality is that such a pledge—and the actions behind it—are essential for a better functioning, better prepared, more effective administration, no matter who it is who swears the oath exactly one year from today.

2016 is shaping up to be a potentially critical year for Afghanistan. ISIS is rising there, the Taliban is gaining ground, the stability of the Afghan government is deteriorating by the day, and national elections are coming in October. The US, China, Pakistan, and the Afghan government are currently holding talks aimed at bringing the Taliban to the table to try negotiate an end to the war.

Of those countries, it's Pakistan that is the most significant. Pakistan has probably the most influence of anyone over whether those talks will succeed in getting the Taliban to agree to sit down and negotiate a peace agreement with the Afghan government. But there's a lot more going on with the peace talks that are perhaps the country's best or only remaining hope.

To understand how this works and why it matters, I spoke to Vanda Felbab-Brown, a senior fellow in the Center for 21st Century Security and Intelligence at the Brookings Institution and an expert on Afghanistan. What follows is a transcript of our conversation, lightly edited for clarity and length.

Jennifer Williams: Could you start by just explaining how Pakistan has been involved in the conflict between the Taliban and Afghanistan historically?

Vanda Felbab-Brown: That goes back to the creation of independent Pakistan, with issues having to do with the Pashtun minority in Pakistan, which is also the majority population of Afghanistan, and irredentist claims by Afghan Pashtun politicians, as well as the Cold War rivalry between the Soviet Union and the United States, who at different times supported either Pakistan or Afghanistan and played the two against each other.

Then you have the Taliban emerging in the 1990s, and Pakistan fully supports the Taliban: They help equip it, they provide intelligence, advisers, and during the Taliban era when they ruled country, Pakistan is one of only three countries that recognize the Taliban regime.

They continued supporting the Taliban throughout the past decade, and US-Pakistan relations became very fraught and complicated. It's never been easy. Pakistanis sometimes use the expression that the United States treats Pakistan like a condom: uses it when they need it then discards it when they are finished with it. It's a fairly common saying in Pakistan, especially in the military. So there is a sense of betrayal on the part of the United States, untrustworthiness, that it's an exploitative relationship on the part of the US toward Pakistan.

I should also say that Pakistan has long supported many Islamic extremist groups as part of its asymmetric policy toward India, and some of these groups have now mutated, or they slipped Pakistan's full control.

Even with respect to the Afghan Taliban, there is a lot of support from the Pakistani state intelligence services and military to the Afghan Taliban. At the same time, Pakistan has been under enormous US and international pressure to act against them, and so they will take the occasional action against the Afghan Taliban as well. But those actions are mostly seen as halfhearted, incomplete window dressing.

JW: So what role is Pakistan playing today? I know that they just had the four-party talks and that Pakistan has been insisting that these talks take place in Pakistan. Are they trying to speak for the Taliban?

VFB: I'm not sure that it's a fair characterization that they are speaking for the Taliban. Certainly the Afghan government, including in the latest talks, often insinuates or alleges that Pakistan speaks for the Taliban. But they clearly do not.

The relationship between the Taliban and Pakistan is hardly smooth and perfect. Many members of the Afghan Taliban deeply resent the level of Pakistani interference, even as the group has been supported by Pakistan. There is a lot of Afghan Pashtun nationalism also among the Taliban that deeply resents the influence and attempts at control by the Pakistani state.

Part of the key issue in the relationship is that although Pakistan supports the Afghan Taliban, and although it has historically supported other extremist groups, it does not have perfect control. And arguably, its control is diminishing. And so they posture, they do their double game. They want to appear strong, and so they posture that they have much greater control than they have, but at the same time they deny that they have any nefarious role.

In reality, they are playing both sides against the middle, and they often have much less capacity to control and rein in the extremist groups, including the Afghan Taliban, than many assume. The widespread criticism of Pakistan is one of its duplicity and its nefarious activity and its lack of willingness to act against the Afghan Taliban. Those are true, but they are also coupled with limits to their capacity. They are riding a tiger that they cannot control fully.

So they have been hosting these four-way talks that involve them, the US government, the Afghan government, and the Chinese government. The Afghan government is desperate to achieve some sort of negotiated deal with the Taliban. It feels under tremendous pressure, the military is taking a pounding from the Taliban, and the government lacks legitimacy.

The US has similar views on the notion that the way out of the predicament in Afghanistan is a negotiated deal. The Chinese also like the idea. They have their own influence in Pakistan. China would very much like to say that they finally achieved what the US failed to do over the past decade, that they will bring peace to Afghanistan, and that they will do it by enabling the negotiations.

Pakistan is responsive to China. Their relationship with China is much stronger than their relationship with the United States. They often tell the US that China is their old friend, that China is the country that hasn't betrayed them, unlike the United States. China has promised massive economic development in Pakistan at $40 billion. The Pakistanis often say to the US that the Pakistan-China relationship is "greater than the Himalayas and deeper than the ocean." Very flowery.

JW: What's the relationship like between the Afghan government and Pakistan today?

VFB: The crucial man there really is the Pakistani chief of the army staff Raheel Sharif; no relation to [Prime Minister] Nawaz Sharif. I think that there is sort of goodwill and motivation right now, even on the army staff — but that is juxtaposed with, again, the limits of control even the chief has. With almost clockwork regularity you have a round of negotiations in Pakistan or you have a meeting between Raheel Sharif and [Afghan President Ashraf] Ghani, and the next day a bomb goes off in Kabul and people die, or the Indian consulate is attacked.

All those ploys are meant to destroy any beginning of a more positive relationship and have been very effective in subverting the process. The same goes on between Pakistan and India. Meanwhile, Ghani is taking an enormously risky strategy with respect to the negotiations. It's vastly unpopular in Afghanistan, and many, many Afghans hate Pakistan and blame it for all of their troubles.

They use Pakistan as the explanation of everything that ever goes wrong in Afghanistan. And the Pakistanis are responsible for a lot, but there's much, much blame and responsibility that lies on Afghan politicians and Afghan people.

So Ghani's outreach and engagement with Pakistan is extremely unpopular. He's spending an extreme amount of political capital, and does not have support from his partner in the government, Abdullah Abdullah, and the northern Tajik factions that hate Pakistan with great vitriol. So the more Pakistan is unable to deliver things like the Haqqani network, reducing or stopping its attacks in Kabul, the more politically impossible for Ghani the process will be.

JW: So what does that mean in terms of the stability of Afghanistan's unity government?

VFB: The unity government is extremely strained. "Unity" it isn't. The Pakistani negotiation angle is just too big for the strain. It might be strategically important. It might be a very significant element in getting any negotiation going, but it's also extremely politically costly, and the longer it doesn't produce anything, the more politically costly and unsustainable it will be.

In October, there are supposed to be parliamentary elections and district elections in Afghanistan, and, more important, this loya jirga [a national assembly of Afghan elders]. And unless there is some sort of major breakthrough by the summer, a lot of the negotiations and political process with both the Taliban and Pakistan will be put on ice, because it will just be politically impossible in the context of the loya jirga and the elections.

So they really have until the summer to make some sort of breakthrough, and then you will have months of morass and extreme political instability in Afghanistan, but it will also not be conducive in any way to improving either the relationship with Pakistan or the negotiations.

JW: How does Pakistan fit into the rise of ISIS in Afghanistan? What's the relationship there? And how might this affect the peace negotiations?

VFB: The rise of ISIS-Khorasan is one of the most interesting developments. It complicates the negotiations for the Taliban. They oppose the negotiations, and they're a big problem for Mullah Mansour and those who want to negotiate. They enable defections, make them easy, and make them costly.

At the same time, it is interesting because ISIS does not have the same linkages to Pakistan that the Afghan Taliban had, even though ISIS includes many defectors from the Taliban. They quite specifically reject what they call the "yoke" that Pakistan has put on the Afghan Taliban, and they call the Afghan Taliban leadership traitors because of the close relationship with Pakistan.

Moreover, ISIS-Khorasan also has quite a few members of various Pakistani extremist groups like Lashkar-e Taiba and members of TTP [Tehrik-e Taliban Pakistan]. So there is also a lot of resentment and hostility toward Pakistan.

I think the rise of ISIS might make Pakistan be cooperative to some extent, but on the other hand, I think it will also reinforce in the mind of many Pakistan security controllers that it's important to cultivate the Afghan Taliban as friends against the bigger danger of ISIS.

JW: Now that ISIS-Khorasan has directly targeted Pakistan, the consulate in Jalalabad, do you think Pakistan will take action?

VFB: I think they'll take action against ISIS and groups like Tehrik-e Taliban. I don't think it will produce more resolve to go after the Afghan Taliban. That's my view. Others are hoping that they will finally accept the realities and really believe that they have to fight all of the insurgents, all of the terrorists, and that they cannot differentiate among them. I am not persuaded that that will, in fact, happen.

JW: So what does this all mean for the prospects for peace? Are you hopeful at all?

VFB: I think the peace negotiations are important, but I am skeptical that anything will happen quickly.

I think that if by summer the Taliban has been willing to join the negotiating table, that will be an important breakthrough, but nothing will be agreed. The summer will be very bloody, and then there will be the political [wrangling] associated with the loya jirga and the elections.

In my view, even if the Taliban comes to the negotiating table, we are looking at years of negotiations, and certainly no breakthrough before 2017 and likely much longer.

And so the question is whether we, the United States, are prepared to stand by with Afghanistan for that long and whether the Afghans will have the resolve. So it's really important that the military and the police fight as hard as they can, because the weaker they fight, the more they defect, the more intimidated they are, the more brain drain that flows from Afghanistan, the stronger the Taliban is viewed and the more intransigent they will be in the negotiations. Now the negotiations will be very much about the military battlefield as much as they will about what's happening at the table for a long time.

This interview was originally published by Vox.

The Seattle city council voted to push up the city’s minimum wage to $15 an hour. If the wage hike is fully implemented, it will guarantee Seattle’s workers the nation’s highest minimum wage. The increase in the minimum wage will be phased in over a number of years. Big employers that do not provide their employees a health plan are the first that will face the $15 per hour minimum, a requirement that will be fully phased in around 2017. Large employers who offer health benefits will have to pay the $15 minimum starting in 2018. Small businesses with employees who receive tip income will have to pay the $15 per hour minimum a couple of years later, but the countable wage will include employees’ tips. By 2021 all employers in the city must offer a minimum wage of $15 an hour, regardless of the employer’s size.

The federal minimum wage is currently just $7.25 an hour, unchanged since 2009. If Congress does not raise the national minimum wage, Seattle’s minimum will be more than twice the federal minimum wage. Many states currently have a higher minimum wage than the federal one. As it happens, Washington has the nation’s highest state-level minimum wage, $9.32 per hour. Unlike the federal minimum wage law, Washington’s state law increases the state minimum wage every year in line with changes in the consumer price index. By the time Seattle’s $15 per hour minimum becomes effective for large employers in 2017, the Washington state minimum wage will be about $10 per hour, assuming consumer prices continue to rise 2% a year. Thus, large employers in Seattle will have to pay their minimum-wage employees 50% more than minimum-wage employees receive outside the Seattle city limits.

I strongly favor the Administration’s proposal to boost the U.S. minimum wage to $10.10 an hour. It will boost the spendable incomes of millions of poorly paid workers and their families, and I expect it will have only a small adverse effect, if any, on low-wage workers’ job opportunities and work hours. However, I am more cautious about the wisdom of raising a single city’s minimum wage to $15 an hour when nearby jurisdictions leave their minimum wages unchanged.

One reason for my caution is that a big minimum-wage hike can place Seattle’s low-wage employers at a competitive disadvantage compared with employers engaged in the same line of business but located in a nearby suburb. If compensation costs for low-wage workers represent a big percentage of a Seattle employer’s costs, and if the employer faces competition from businesses on the other side of the city limits, companies located in Seattle can lose customers to competitors outside the city.

Consider a business that mainly sells low-cost, fast-food meals. If it must pay $15 an hour to its low-wage employees, while its competitors less than a mile away are only required to pay $10 an hour, the companies outside Seattle can charge lower prices to their customers for shakes, burgers, and fries, and yet still make a profit. The lower cost establishments can capture a larger percentage of the local fast-food trade, reducing fast-food sales inside Seattle’s city limits. The same is true of the goods and services sold by laundry and dry cleaning establishments, inexpensive motels, and other businesses that depend on low-wage workers to stay competitive. The labor cost disadvantage caused by a higher minimum wage can hurt low-wage employment in Seattle and possibly reduce the value of some of the city’s commercial real estate.

To the extent that consumers have the option of buying goods or services from companies that are not required to pay a higher minimum wage, some of the hoped-for gains from a higher minimum wage will be lost. When customers can conveniently buy products or services from firms that face lower labor costs, the new businesses that they patronize will grow and the old, high-cost businesses they abandon will shrink. Low-wage workers may earn higher wages inside the Seattle city limits, but their employment opportunities in Seattle may shrink.

Seattle is a prosperous city, and its mayor was elected in part because of a promise to boost the pay of its most poorly paid residents. If a $15 an hour minimum wage has a chance of working and enjoying broad political support, Seattle is a good place to test the idea. I will be interested to see whether low-wage Seattle businesses continue to prosper even after they are required to pay a minimum wage that is 50% higher than the one faced by competitors in nearby suburbs. The risk of a big minimum-wage hike at the city level is that the city’s low-wage employers will be harmed in their competition with out-of-town businesses that sell the same products or services. The risk of this kind of harm is vastly smaller when the minimum wage is increased at the state or national level. If the Administration can persuade Congress to boost the national minimum wage, all employers—inside and outside a city’s limits—will be required to raise the pay they offer to their most poorly paid workers.

Note: An edited version of this post appears on Fortune.com

After years of irresponsible fiscal management, Puerto Rico has few good options to address its growing debt crisis. But in most tales of bad behavior, there comes a point where continued punishment for past mistakes becomes counterproductive. We're reaching that point on Puerto Rico, and the Barack Obama administration has put forward a sensible new approach. 

(Citigroup, my employer, has various business relationships with Puerto Rico, including serving as underwriter and market maker in various securities. I've had no involvement in those activities, and this column represents my personal views, not those of Citi.)

Puerto Rico's population and its economy are about 10 percent smaller than they were a decade ago. The poverty rate is 45 percent, only about 40 percent of adults are in the labor force, and unemployment is more than 11 percent. 

Given these dire economic indicators, it's not surprising that Puerto Rico has a serious debt problem. At this point, the territory's total liabilities amount to more than 160 percent of the economy, and debt service is projected to be more than a third of government revenue. Over the next five years, the fiscal deficit looks to be $28 billion, and although the Puerto Rican government has proposed aggressive policy actions, these could, at best, only cut the deficit in half. Because the territory's fiscal dynamic is unsustainable, its uninsured debt is selling at discounts of 30 to 70 percent. 

Something has to give. Which brings us to the White House's plan.

The first imperative is to restore economic growth. For this, there are no magic bullets, but one useful strategy is to extend the Earned Income Tax Credit to Puerto Rico. The EITC is one of the most powerful, market-friendly mechanisms for encouraging labor force participation, and its absence in Puerto Rico makes no sense.

The Obama administration also proposes removing an anomaly in the Medicaid system. If Medicaid treated Puerto Rico in the same way as it does the 50 states, the federal government would pay for an estimated 83 percent of its Medicaid costs. But because Medicaid payments to the territory are capped, the federal government has generally paid only 15 to 20 percent. In addition, temporary Medicaid payments enacted as part of the Affordable Care Act are almost exhausted, posing a near-term threat to Puerto Rico's Medicaid program.

Establishing an EITC in Puerto Rico and adjusting the share of Medicaid payments paid by the federal government make sense from a fairness perspective. The EITC piece would encourage work, and the Medicaid component would attenuate fiscal pressure on the island. These steps would, though, come at a cost to the federal budget, probably in the billions of dollars per year. The administration should clarify both the amounts involved and how they would be financed. 

The island's fiscal governance also needs to be strengthened. Its accounting systems have been shoddy, and revenue estimates have been overly rosy. A period of external oversight is appropriate, to improve transparency and budgetary rigor. 

Finally, there's the hard question of what to do about the existing overhang of debt. Write-offs are inevitable; the only question is how to do them in a structured and timely way. We have bankruptcy laws precisely to handle this sort of situation, which would otherwise involve overlapping negotiations with multiple creditors (Puerto Rico has 18 different debt issuers and 20 creditor committees) and probably extended lawsuits. 

At the very least, Congress should extend Chapter 9 bankruptcy laws to Puerto Rico's cities and public corporations. Municipalities in the states enjoy this protection, and there's no reason to treat cities in Puerto Rico differently than those in Florida or Texas. This step would cover about a third of the territory's debt. 

The more controversial question, though, is whether Puerto Rico's government should also have access to bankruptcy protection. State governments do not, but the administration proposes that territories such as Puerto Rico should. 

Bankruptcy would not necessarily mean that less debt would be repaid. So it is not clear that the traditional argument against bankruptcy protection -- that it would raise future borrowing costs -- carries much force. Negotiated write-offs and default would have largely the same effect, but would probably take longer and be messier. Among the options left, the administration's is the least bad. 

The plan requires legislation, and in today's polarized Congress, that's a daunting prospect. But as former Treasury Secretary Tim Geithner once emphasized, in a crisis, "plan beats no plan." the administration has one. Its congressional opponents don't.

Editor's Note: this op-ed originally appeared on Bloomberg View.

Event Information

The Metropolitan Policy Program at Brookings, hosted The Political Geography of America's Purple States: Five Trends That Will Decide the 2008 Election, a briefing on a new series of reports on the political demography of "purple" states in the 2008 election.

Purple states-or states where the current balance of political forces does not decisively favor one party or the other-will play an undeniably pivotal role in the upcoming election and include: Virginia and Florida in the South; the Intermountain West states of Colorado, New Mexico, Nevada, and Arizona; Michigan, Missouri, and Ohio in the Heartland; and Pennsylvania.

On October 10, 2008 at the National Press Club in Washington DC, authors William Frey and Ruy Teixeira highlighted the political and demographic trends in these 10 battleground states, focusing not only on their role in the 2008 election, but their position as toss-ups in years to come.

The session opened with an overview of the demographic shifts shaping all the contested states studied, and evolved into a detailed presentation of the trends that are testing and reshaping the balance of their voting populations, focusing particularly on five trends that Frey and Teixeira believe will decide the 2008 election. Feedback from James Barnes, political correspondent for the National Journal, helped shape the conversation.

Event Materials

• Agenda
• Presentation
• Biographies

As a rhetorical ideal, greater opportunity is hard to beat. Just about all candidates for high elected office declare their commitments to promoting opportunity – who, after all, could be against it? But opportunity is, to borrow a term from the philosopher and political theorist Isaiah Berlin, a "protean" word, with different meanings for different people at different times.

Typically, opportunity is closely entwined with an idea of upward mobility, especially between generations. The American Dream is couched in terms of a daughter or son of bartenders or farm workers becoming a lawyer, or perhaps even a U.S. senator. But even here, there are competing definitions of upward mobility.

It might mean being better off than your parents were at a similar age. This is what researchers call "absolute mobility," and largely relies on economic growth – the proverbial rising tide that raises most boats.

Or it could mean moving to a higher rung of the ladder within society, and so ending up in a better relative position than one's parents.

Scholars label this movement "relative mobility." And while there are many ways to think about status or standard of living – education, wealth, health, occupation – the most common yardstick is household income at or near middle age (which, somewhat depressingly, tends to be defined as 40).

As a basic principle, we ought to care about both kinds of mobility as proxies for opportunity. We want children to have the chance to do absolutely and relatively well in comparison to their parents.

On the One Hand…

So how are we doing? The good news is that economic standards of living have improved over time. Most children are therefore better off than their parents. Among children born in the 1970s and 1980s, 84 percent had higher incomes (even after adjusting for inflation) than their parents did at a similar age, according to a Pew study. Absolute upward income mobility, then, has been strong, and has helped children from every income class, especially those nearer the bottom of the ladder. More than 9 in 10 of those born into families in the bottom fifth of the income distribution have been upwardly mobile in this absolute sense.

There's a catch, though. Strong absolute mobility goes hand in hand with strong economic growth. So it is quite likely that these rates of generational progress will slow, since the potential growth rate of the economy has probably diminished. This risk is heightened by an increasingly unequal division of the proceeds of growth in recent years. Today's parents are certainly worried. Surveys show that they are far less certain than earlier cohorts that their children will be better off than they are.

If the story on absolute mobility may be about to turn for the worse, the picture for relative mobility is already pretty bad. The basic message here: pick your parents carefully. If you are born to parents in the poorest fifth of the income distribution, your chance of remaining stuck in that income group is around 35 to 40 percent. If you manage to be born into a higher-income family, the chances are similarly good that you will remain there in adulthood.

It would be wrong, however, to say that class positions are fixed. There is still a fair amount of fluidity or social mobility in America – just not as much as most people seem to believe or want. Relative mobility is especially sticky in the tails at the high and low end of the distribution. Mobility is also considerably lower for blacks than for whites, with blacks much less likely to escape from the bottom rungs of the ladder. Equally ominously, they are much more likely to fall down from the middle quintile.

Relative mobility rates in the United States are lower than the rhetoric about equal opportunity might suggest and lower than people believe. But are they getting worse? Current evidence suggests not. In fact, the trend line for relative mobility has been quite flat for the past few decades, according to work by Raj Chetty of Stanford and his co-researchers. It is simply not the case that the amount of intergenerational relative mobility has declined over time.

Whether this will remain the case as the generations of children exposed to growing income inequality mature is not yet clear, though. As one of us (Sawhill) has noted, when the rungs on the ladder of opportunity grow further apart, it becomes more difficult to climb the ladder. To the same point, in his latest book, Our Kids – The American Dream in Crisis, Robert Putnam of Harvard argues that the growing gaps not just in income but also in neighborhood conditions, family structure, parenting styles and educational opportunities will almost inevitably lead to less social mobility in the future. Indeed, these multiple disadvantages or advantages are increasingly clustered, making it harder for children growing up in disadvantaged circumstances to achieve the dream of becoming middle class.

The Geography of Opportunity

Another way to assess the amount of mobility in the United States is to compare it to that found in other high-income nations. Mobility rates are highest in Scandinavia and lowest in the United States, Britain and Italy, with Australia, Western Europe and Canada lying somewhere in between, according to analyses by Jo Blanden, of the University of Surrey and Miles Corak of the University of Ottawa. Interestingly, the most recent research suggests that the United States stands out most for its lack of downward mobility from the top. Or, to paraphrase Billie Holiday, God blesses the child that's got his own.

Any differences among countries, while notable, are more than matched by differences within Pioneering work (again by Raj Chetty and his colleagues) shows that some cities have much higher rates of upward mobility than others. From a mobility perspective, it is better to grow up in San Francisco, Seattle or Boston than in Atlanta, Baltimore or Detroit. Families that move to these high-mobility communities when their children are still relatively young enhance the chances that the children will have more education and higher incomes in early adulthood. Greater mobility can be found in places with better schools, fewer single parents, greater social capital, lower income inequality and less residential segregation. However, the extent to which these factors are causes rather than simply correlates of higher or lower mobility is not yet known. Scholarly efforts to establish why it is that some children move up the ladder and others don't are still in their infancy.

Models of Mobility

What is it about their families, their communities and their own characteristics that determine why they do or do not achieve some measure of success later in life?

To help get at this vital question, the Brookings Institution has created a life-cycle model of children's trajectories, using data from the National Longitudinal Survey of Youth on about 5,000 children from birth to age 40. (The resulting Social Genome Model is now a partnership among three institutions: Brookings, the Urban Institute and Child Trends). Our model tracks children's progress through multiple life stages with a corresponding set of success measures at the end of each. For example, children are considered successful at the end of elementary school if they have mastered basic reading and math skills and have acquired the behavioral or non-cognitive competencies that have been shown to predict later success. At the end of adolescence, success is measured by whether the young person has completed high school with a GPA average of 2.5 or better and has not been convicted of a crime or had a baby as a teenager.

These metrics capture common-sense intuition about what drives success. But they are also aligned with the empirical evidence on life trajectories. Educational achievement, for example, has a strong effect on later earnings and income, and this well-known linkage is reflected in the model. We have worked hard to adjust for confounding variables but cannot be sure that all such effects are truly causal. We do know that the model does a good job of predicting or projecting later outcomes.

Three findings from the model stand out. First, it's clear that success is a cumulative process. According to our measures, a child who is ready for school at age 5 is almost twice as likely to be successful at the end of elementary school as one who is not.

This doesn't mean that a life course is set in stone this early, however.

Children who get off track at an early age frequently get back on track at a later age; it's just that their chances are not nearly as good. So this is a powerful argument for intervening early in life. But it is not an argument for giving up on older youth.

Second, the chances of clearing our last hurdle – being middle class by middle age (specifically, having an income of around $68,000 for a family of four by age 40) – vary quite significantly. A little over half of all children born in the 1980s and 1990s achieved this goal. But those who are black or born into low-income families were very much less likely than others to achieve this benchmark.

Third, the effect of a child's circumstances at birth is strong. We use a multidimensional measure here, including not just the family's income but also the mother's education, the marital status of the parents and the birth weight of the child. Together, these factors have substantial effects on a child's subsequent success. Maternal education seems especially important.

The Social Genome Model, then, is a useful tool for looking under the hood at why some children succeed and others don't. But it can also be used to assess the likely impact of a variety of interventions designed to improve upward mobility. For one illustrative simulation, we hand-picked a battery of programs shown to be effective at different life stages – a parenting program, a high-quality early-edcation program, a reading and socio-emotional learning program in elementary school, a comprehensive high school reform model – and assessed the possible impact for low-income children benefiting from each of them, or all of them.

No single program does very much to close the gap between children from lower- and higher-income families. But the combined effects of multiple programs – that is, from intervening early and often in a child's life – has a surprisingly big impact. The gap of almost 20 percentage points in the chances of low-income and high-income children reaching the middle class shrinks to six percentage points. In other words, we are able to close about two-thirds of the initial gap in the life chances of these two groups of children. The black-white gap narrows, too.

Looking at the cumulative impact on adult incomes over a working life (all appropriately discounted with time) and comparing these lifetime income benefits to the costs of the programs, we believe that such investments would pass a cost-benefit test from the perspective of society as a whole and even from the narrower prospective of the taxpayers who fund the programs.

What Now?

Understanding the processes that lie beneath the patterns of social mobility is critical. It is not enough to know how good the odds of escaping are for a child born into poverty. We want to know why. We can never eliminate the effects of family background on an individual's life chances. But the wide variation among countries and among cities in the U.S. suggests that we could do better – and that public policy may have an important role to play. Models like the Social Genome are intended to assist in that endeavor, in part by allowing policymakers to bench- test competing initiatives based on the statistical evidence.

America's presumed exceptionalism is rooted in part on a belief that class-based distinctions are less important than in Western Europe. From this perspective, it is distressing to learn that American children do not have exceptional opportunities to get ahead – and that the consequences of gaps in children's initial circumstances might embed themselves in the social fabric over time, leading to even less social mobility in the future.

But there is also some cause for optimism. Programs that compensate at least to some degree for disadvantages earlier in life really can close opportunity gaps and increase rates of social mobility. Moreover, by most any reasonable reckoning, the return on the public investment is high.

Editor's note: This piece originally appeared in the Milken Institute Review.