Brookings: Latest From Brookings

Confronting Suburban Poverty in America

Alan Berube and Elizabeth Kneebone — Mon, 20 May 2013 00:00:00 -0400

Brookings Institution Press 2013 184pp.

Event:

On May 20, the Metropolitan Policy Program at Brookings will host an event marking the release of Confronting Suburban Poverty in America, co-authored by Elizabeth Kneebone and Alan Berube. They, along with some of the nation’s leading anti-poverty experts, including Luis Ubiñas, president of the Ford Foundation, and Bill Shore, founder and CEO of Share our Strength, will join leading local innovators from across the country to discuss a new metropolitan opportunity agenda for addressing suburban poverty, how federal and state policymakers can deploy limited resources to address a growing challenge, and why building on local solutions holds great promise.

Synopsis:

It has been nearly a half century since President Lyndon Johnson declared his War on Poverty, setting in motion development of America’s modern safety net. Back in the 1960s, tackling poverty “in place” meant focusing resources in the inner city and in isolated rural areas. The suburbs were home to middle- and upper-class families—affluent commuters and homeowners who did not want to raise kids in the city. But the America of 2012 is a very different place. Poverty is no longer just an urban or rural problem but increasingly a suburban one as well.

In Confronting Suburban Poverty in America, Elizabeth Kneebone and Alan Berube take on the new reality of metropolitan poverty and opportunity in America. For decades, suburbs added poor residents at a faster pace than cities, so that suburbia is now home to more poor residents than central cities, composing over a third of the nation’s total poor population. Unfortunately, the antipoverty infrastructure built over the past several decades does not fit this rapidly changing geography. The solution no longer fits the problem. Kneebone and Berube explain the source and impact of these important developments; moreover, they present innovative ideas on addressing them.

The spread of suburban poverty has many causes, including job sprawl, shifts in affordable housing, population dynamics, immigration, and a struggling economy. As the authors explain in Confronting Suburban Poverty in America, it raises a number of daunting challenges, such as the need for more (and better) transportation options, services, and financial resources. But necessity also produces opportunity—in this case, the opportunity to rethink and modernize services, structures, and procedures so that they better reflect and address new demands. This book embraces that opportunity.

The authors put forward a series of workable recommendations for public, private, and nonprofit leaders seeking to modernize poverty alleviation and community development strategies and connect residents with economic opportunity. They describe and evaluate ongoing efforts in metro areas where local leaders are learning how to do more with less and adjusting their approaches to address the metropolitan scale of poverty—for example, collaborating across sectors and jurisdictions, using data and technology in innovative ways, and integrating services and service delivery. Kneebone and Berube combine clear prose, original thinking, and illustrative graphics in Confronting Suburban Poverty in America to paint a new picture of poverty in America as well as the best ways to combat it.

ABOUT THE AUTHORS

Alan Berube

Elizabeth Kneebone

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A Statesman’s Forum with H.E. Recep Tayyip Erdoğan, Prime Minister of Turkey

Fri, 17 May 2013 10:30:00 -0400

Event Information

May 17, 2013
10:30 AM - 12:00 PM EDT

Online Only
Live Webcast

Webcast Archive:

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On May 17, the Center on the U.S. and Europe at Brookings hosted a Stateman's Forum with Turkish Prime Minister Recep Tayyip Erdoğan. In his remarks, Mr. Erdoğan reflected on three terms of Justice and Development Party (AK Party) leadership during a period of rapid evolution for Turkey and its role in the world.

Recep Tayyip Erdoğan became Prime Minister of Turkey in March 2003, following the electoral success in 2002 of the AK Party. In the 2007and 2011 elections, the AK Party was returned to power with landslide victories in Turkey's parliamentary elections, making Mr. Erdoğan the longest-serving prime minister in Turkish history. Previously, Mr. Erdoğan served as Mayor of Istanbul from 1994 to 1997. He was educated at Marmara University.

Brookings President Strobe Talbott introduced Mr. Erdoğan. At the conclusion of the Prime Minister's remarks, Brookings TUSIAD Senior Fellow Kemal Kirişci moderated a discussion.

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The Affordable Care Act: From Hiccups to Repeal

Elaine Kamarck — Wed, 15 May 2013 17:34:00 -0400

Note: On Monday, May 20, Elaine Kamarck, director of the Management and Leadership Initiative at Brookings, will moderate a public forum on "Implementing the Affordable Care Act: Organizational and Political Challenges."

It's been a long time since the federal government had to implement a large, new, federal program. Ten years ago we saw the implementation of Medicare Part D and the creation of a new cabinet department, the Department of Homeland Security. In each instance there were predictions of disaster and substantial growing pains. In the case of Medicare Part D implementation exceeded expectations and costs have not been nearly as high as feared. In the case of DHS, implementation was bumpier, nonetheless, ten years later both operate more or less smoothly and, in retrospect, the crisis now seems overblown.

This year, the Obama administration needs to finalize implementation of the Affordable Care Act—a historic piece of legislation and the most significant domestic policy achievement of the Obama administration to date. And the question of how it goes is front and center. Even the president has admitted that there will be “hiccups” along the way. Compared to earlier pieces of health care legislation, the ACA is incredibly complex, involving activity by fifty states, the jurisdiction of fifty state insurance regulators and changes in the entire health care industry. Added to the inherent complexity of the bill is the fact that it had no Republican support and is still adamantly opposed by the Republican party and by half of all those polled.

So the question is: how bad will it be? Imagine a continuum that goes from “hiccup” on one end to repeal on the other end. With plenty of points in the middle. What would that look like?

The hiccup scenario is the most optimistic. Hiccups are more or less normal. If the implementation is successful, the exchanges will be up and running. There will be glitches. Some people who qualify won’t get their subsidies; some who don’t will. The number of companies on the exchanges won’t be as big as hoped for but will grow. Premiums for health care will rise only modestly and the enhanced services in the new health care plans will make most people okay with the price increase.

The delay scenario is not really good nor is it fatal. A less successful outcome is one where the feds and states find they have to pull back from key provisions in the bill at least for a while. There may be delays in opening exchanges which would necessitate delays in enforcing the mandate that everyone buy insurance. The federal hub may not be able to interface with statewide data and eligibility could become a lengthy bureaucratic process. HHS might adopt a generous waiver policy while states work out their systems. Premiums may rise, leading to complaints from the public but no substantial drops in insurance buying.

The repeal scenario is fatal. Obviously Republicans, especially in the House, are rooting for this one. In fact they seem to like taking the repeal vote so much that they’ve done it 37 times in the past three years. So the question is: what would it take to move support for repeal beyond the Republican base? In 1989 Congress repealed the Medicare Catastrophic Coverage Act a short sixteen months after it was passed. Why? It increased costs to seniors and offered them things that they didn’t want. In the context of ACA the repeal scenario is feasible if premium prices rise so high that people who don’t qualify for subsidies (there are more of them than those who do) decide that they really don’t want the enhanced packages envisioned in the law and then get really mad and let their representatives know it.

Where will we end up? Stay tuned.

Authors

Elaine Kamarck

Image Source: © Jonathan Ernst / Reuters

Federal Tax Reform? Don't Bet The Rent Money On It

Bill Frenzel — Tue, 14 May 2013 11:52:00 -0400

In some years there are no budgets. This year we have been presented with thre dueling budgets, one from each house and one from the president. Neither house has picked conferees, and neither has any current inclination to do so. Each prefers to glare at the other until the next election day.

The “Grand Bargain” on the Federal budget this year is still possible, but it seems less and less likely. The prospect is for another year of small deals, recurring crises, and several continuing resolutions.

As hopes for the big fiscal fix recede, tax reform moves to center stage. Ideally, tax reform ought to be a part of a larger budget agreement. But, with that agreement now slipping out of reach for 2013, tax reform seems to some observers to be a more promising suspect.

Tax reform appeals to both parties for different reasons. Democrats need it for new spending to stimulate growth. Republicans want to use it for lowering tax rates for the same reason. Those differences may be irreconcilable, but members of Congress seem to want to give tax reform a try.

Perhaps the best reason for tax reform optimism lies in the fact that the chairmen of both tax-writing committees really want to do it. Dave Camp, chair of the House Ways & Means Committee, is now serving his last term as chair under caucus rules. Max Baucus, Camp’s Senate Finance Committee counterpart, is in a similar position. He is retiring from Congress after this term.

Both of these leaders are strongly motivated to produce a tax bill before they slide into history. Both are able veterans who know the tax code. They meet regularly. Both have held hearings on tax reform, and have given it much study over the past two years. In addition, Camp has the blessing of the House Republican leadership including Speaker Boehner, who has saved the precious number, HR 1, for a tax reform bill.

Some business interests, led by the U.S. Chamber of Commerce, want to see reform of the tax code, too. Many of them see advantages in potentially lower rates, and in reform of U.S. taxation of their foreign income. American business is by no means unified on this subject, but there clearly is plenty of interest.

There is, however, another side to the tax reform story. Historically, it is a rare event. The last successful effort was in 1986. Before that one has to backtrack to 1958 to identify a major tax reform enactment. In the 1986 version, both Congressional parties, (with Democrats in the majority) and the President, Ronald Reagan, strongly supported it. Even so, the process took two years. Nobody believes that the 1986 political consensus can be duplicated today.

In 1986, the American people polled strongly in favor of tax reform. Nowadays, they are not so sure. They saw the 1986 act substantially altered by amendment in the years immediately thereafter. Today, the public is not sure that tax reform will help them. And, even if it does help, they are pretty sure it will soon be amended beyond recognition. Trust in the government has all but faded away in the last three decades.

In the end, the biggest hurdle for tax reform will be to overcome the opposition of interests who are unwilling to part with their tax preferences peaceably. Unsurprisingly, many individuals and corporations just love their tax preferences. Some of them would be worse off with a system that abolished those preferences even if their basic tax rates were lowered.

This group is sophisticated. It knows how to make strategic political contributions, and it knows how to lobby successfully. It also knows how to maneuver in the current political environment where polarization is the rule, and in which members of Congress do not often trust one another. For these interests, the conditions on the playing field are just about perfect for defending their preferences.

Just as the country needs a Grand Bargain, it also needs tax reform. It would be wonderful if tax reform could be achieved this year. The two chairmen and many members will give the good old college try. But, if a budget compromise is not possible, it also seems unlikely that a good tax reform bill can be enacted. Cheer for tax reform; pray for it; just don’t bet the rent money on it.

Authors

Bill Frenzel

Publication: Forbes

Image Source: © Kevin Lamarque / Reuters

Alleviating Poverty: Mobile Communications, Microfinance and Small Business Development Around the World

Darrell M. West — Thu, 16 May 2013 12:00:00 -0400

Editor’s Note: The Center for Technology Innovation at Brookings releases this paper in conjunction with the May 16 forum at Brookings, “Mobile Technology’s Role in Combating Global Poverty and Enabling Entrepreneurship.” Both are part of the wider Mobile Economy Project which examines how the rapid expansion of mobile technology around the world is transforming economic opportunity for millions.

Poverty is one of the most pressing problems around the world. According to statistics from the World Bank, nearly one-quarter of the global population lives at or below the poverty line of $1.25 per day.[i] With so many people struggling for basic subsistence, it is hard for those affected to get out of poverty, gain access to capital, or develop small firms or businesses that help them build a better life.

Yet with the growth of mobile technology, there are new opportunities for individuals and small businesses to lift themselves up. People can use handheld devices to make monetary transfers, arrange for microfinance loans, establish small enterprises, and improve their economic circumstances. This helps them alleviate poverty and create a better situation for themselves and their families.

Jeffrey Sachs, director of Columbia University's Earth Institute, said that wireless communication is a breakthrough technology that helps to solve the worst problems associated with health care, poverty, and educational access. "Now in every village where I go, someone's got a cell phone, somebody can make an emergency call, someone can find out the price on the market, someone can start a business empowered by the fact that they can reach a customer or a supplier, someone can drive a taxi or a truck for that reason as well. Everything is changing," said Sachs.[ii]

In this Mobile Economy Project report, Darrell West looks at the growth of handheld devices and investigates the barriers to doing business in the developing world. In particular, West explores how mobile devices enable individual entrepreneurship and small business development. Despite the presence of barriers such as corruption, lack of transparency and capital, and poor infrastructure in many parts of the developing world, there are successful ventures enabled by mobile technology.

The report details some of the cases which illustrate emerging possibilities for alleviating poverty in different countries including:

The growth of mobile devices
Mobile money transfer services
Mobile tools for small businesses
Microfinance applications

[i] World Bank data is found at http://povertydata.worldbank.org/poverty/home/.

[ii] Kyla Yeoman, “Can Mobile Phones End Extreme Poverty?”, Global Envision, March 16, 2012.

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Authors

Darrell M. West

Image Source: © Mike Hutchings / Reuters

H-1B Visas and the STEM Shortage

Jonathan Rothwell and Neil G. Ruiz — Fri, 10 May 2013 11:01:00 -0400

Last month, a landmark immigration reform bill was introduced in the U.S. Senate that has the potential to both increase the number of available H-1B visas for foreigners working in specialty occupations and shift the U.S. employment-based visa system to a more merit-based scheme favoring science, technology, engineering, and mathematics (STEM) workers.

As it stands today, businesses say they cannot find the skills they need in the domestic labor pool and need access to a global pool of STEM workers. Bolstering their contention are a number of studies that suggest that STEM jobs exhibit characteristics of under-supply: high wages and low unemployment.

Yet, some analysts have argued that there are plenty of U.S. native-born workers who can do these jobs. They claim that H-1B workers do not have special skills but instead are preferred because they are paid lower wages.

Without attempting to fully resolve this complex issue, new detailed data on H-1B wages by occupation, presented more fully here, suggests that the H-1B program helps to fill a shortage of workers in STEM occupations.

Employers request H-1B visas for hard-to-fill STEM jobs. The vast majority—90 percent—of H-1B applications are for jobs requiring high-level STEM knowledge. This finding is based on our analysis of Department of Labor survey data on the knowledge needed to perform occupations. The evidence shows that these vacancies are harder-to-fill than other job openings.

Labor market experts interpret the duration of a job opening as an indicator that qualified candidates are hard to find. Such an interpretation of vacancy survey data is empirically grounded in both historical and many contemporary labor market surveys from private firms and state governments.

Using 2011 job openings data from the Conference Board for the 100 largest metropolitan areas, we find that 43 percent of job vacancies for STEM occupations with H-1B requests are reposted after one month of advertising, implying that they are unfilled. By contrast 38 percent of vacancies in non-STEM occupations requiring a bachelor’s degree go unfilled after one month, and just 32 percent of job postings for all non-STEM occupations. In a statistical analysis of over 50,000 openings, we find that those requiring STEM knowledge take significantly longer to fill, even controlling for requirements for education, experience, training, and managerial knowledge, as well as wage rates and metropolitan area location. The most commonly requested H-1B occupations in each metropolitan area also take longer to fill.

H-1B visa holders earn more than comparable native-born workers. H-1B workers are paid more than U.S. native-born workers with a bachelor’s degree generally ($76,356 versus $67,301 in 2010) and even within the same occupation and industry for workers with similar experience. This suggests that they provide hard-to-find skills.

To reach this conclusion, we analyzed 2010 H-1B petitions obtained from labor economists Magnus Lofstrom and Joe Hayes through a Freedom of Information Act (FOIA) request filed at the U.S. Citizenship and Immigration Services. We combined these data with micro-records from the American Community Survey to compare employed the U.S. native-born with a bachelor’s degree to their H-1B counterparts.

Like Lofstrom and Hayes, we find that H-1B workers earn more than Americans in the same occupation and age cohort. The 20 most common cohort-minor occupation combinations found in the H-1B program are listed below. These groups comprise roughly three-quarters of all H-1B workers in the database. In 17 of the 20 groups, wages are significantly higher for H-1B workers, and there is a significant negative difference only for life scientists aged 30 to 35. For the three largest computer occupation groups, wages are much higher.

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Wages are increasing in occupations with most H-1B requests. In recent years, from 2009 to 2011, nominal wage growth for U.S.-born workers with at least a bachelor’s degree has been high for the most prominent H-1B occupations. The average native-born worker experienced flat annual growth in wages over that period (0.0 percent), but wage growth for those in computer occupations—the largest H-1B category—grew by 1.3 percent each year since 2009 and 2.7 percent each year since 2000 for those with a bachelor’s degree. Wage growth was even higher for engineers, with 2.1 percent growth since 2009 and 3 percent growth since 2000.

For every prominent H-1B occupational category except life scientists and operations specialties managers, wage growth was stronger than the national average since 2009. Since 2000, all but postsecondary teachers have seen higher than average wage growth.

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There are two important caveats. First, hard-to-fill high-skilled jobs do not always require many years of post-secondary training. Even among H-1B visa requests, about 25 percent are for occupations that typically require only an associate’s degree, meaning that the current U.S. workforce could be trained to do these jobs at relatively little cost. Second, not all STEM jobs are experiencing the same symptoms of shortage.

A data-driven bureau is needed to identify occupational shortages. Overall, there is compelling evidence that the H-1B visa program is helping to alleviate acute shortages in various occupations. Yet, because of data limitations, the evidence is far from complete. If the Senate bill is passed into law, the proposed Bureau on Immigration and Labor Market Research should collect better information from employers about job openings, including occupations, the number of qualified applicants, the number of interviews conducted, and the length of time it takes to fill the job. Likewise, the bureau should also consider how demand and supply play out in regional or metropolitan area labor markets, since job search and recruitment often happen locally. Armed with such information, as well as indicators presented above, visas and public funding for training and education in hard-to-fill occupations could be more confidently allocated.

Authors

Image Source: © Brian Snyder / Reuters

Mapping the African Growth Landscape

Mwangi S. Kimenyi — Wed, 15 May 2013 13:29:00 -0400

Editor's Note: In this piece, Mwangi Kimenyi discusses Africa's integration following the session "Mapping the African Growth Landscape," held at this year's the World Economic Forum on Africa.

The session on Mapping the African Growth Landscape focused on the sectors that hold the greatest potential for economic growth in Africa. The session started with each of the participants voting for three sectors that they considered as having highest potential for growth. The sectors selected by most of the participants were: information communication technology and telecommunications; energy and engineering; entrepreneurship; education; manufacturing; and agriculture. The selection of these sectors was influenced not only by their potential to contribute to the growth of the economies, but also to creating jobs, especially for the youth.

Working in groups, participants identified opportunities and strategies for exploiting the economic growth potentials that the various sectors offer. Although many of the opportunities and strategies identified were specific to particular sectors, there were also some common themes. For example, innovation was identified as a source of potential growth in all sectors. This includes advances in the ICT sector, innovations in the delivery of education to ensure quality instruction or innovative approaches, developing entrepreneurship through entrepreneurship hubs and incubators or even innovations to improve governance using ICT. Innovation was also considered key to expanding the manufacturing sector and in agriculture, such as the introduction of genetically modified seeds. Participants were of the opinion that Africans must embrace innovations to fully exploit the growth opportunities of various sectors.

Participants focused on actions to exploit the growth potential afforded by the various sectors. The ICT sector was identified as having great potential for growth through expansion of mobile penetration with applications in health and industry. The sector was identified as presenting immense opportunity through the compilation of information on the population, which would assist in policies for the delivery of health services and in tax collection. Participants observed that the energy sector presents many opportunities for growth, but there is need to develop a forward-looking energy master plan for Africa, not just for individual countries. Many opportunities also exist for a diverse mix of energy sources including solar, hydro and thermal.

Read the full commentary and watch the related video »

Authors

Mwangi S. Kimenyi

Publication: World Economic Forum

Image Source: © Reuters Staff / Reuters

Eyes in the Sky: The Domestic Use of Unmanned Aerial Systems

John Villasenor — Fri, 17 May 2013 09:56:00 -0400

Editor's Note: On May 17, John Villasenor testified before the House Judiciary Committee on the important topic of privacy and unmanned aircraft systems, often referred to as drones.

Good morning Chairman Sensenbrenner, Ranking Member Scott, and Members of the Subcommittee. Thank you very much for the opportunity to testify today on the important topic of privacy and unmanned aircraft systems (UAS).^{^[1]}

I am a nonresident senior fellow in Governance Studies and the Center for Technology Innovation at the Brookings Institution. I am also a professor at UCLA, where I hold appointments in the Electrical Engineering Department and the Department of Public Policy. The views I am expressing here are my own, and do not necessarily represent those of the Brookings Institution or the University of California. Portions of my testimony today are adapted from a law review article I recently published in the Harvard Journal of Law and Public Policy.^{^[2]}

UAS, often referred to as “drones,” can be employed in an endless variety of civilian applications, the overwhelming majority of them beneficial. However, like any technology, UAS can also be misused. The most common concern regarding domestic UAS relates to their potential impact on privacy. This is a legitimate concern. Existing laws and jurisprudence provide an important foundation, but they also leave many questions unanswered.

For non-government operators, determining when UAS use violates privacy involves the tension between First Amendment freedoms and common law and statutory privacy protections. With respect to government-operated UAS, the Fourth Amendment is of course central to the privacy question. While the Supreme Court has never explicitly considered warrantless observations using UAS, a careful examination of Supreme Court privacy jurisprudence suggests that the Constitution will provide a much stronger measure of protection against government UAS privacy abuses than is widely appreciated. The Fourth Amendment has served us well since its ratification in 1791, and there is no reason to suspect it will be unable to do so in a world where unmanned aircraft are widely used.

This does not mean that there is no need for additional statutory UAS privacy protections. However, when drafting new laws it is critical to adopt a balanced approach that recognizes the inherent difficulty of predicting the future of any rapidly changing technology. Although unmanned aircraft pose real and increasingly well-recognized privacy concerns, they also offer real and much less widely understood benefits. A dialog conducted with full awareness of this balance will be much more likely to lead to positive policy outcomes.

[1] The acronym “UAS” is also sometimes expanded to “unmanned aerial systems.”

[2] John Villasenor, Observations From Above: Unmanned Aircraft Systems and Privacy, 36 Harv. J.L. & Pub. Pol'y 457 (2013).

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Authors

John Villasenor

Image Source: © Handout . / Reuters

GCI Houston: Greater Houston and the Next Economy

Bruce Katz — Wed, 15 May 2013 00:00:00 -0400

Editor's Note: On May 15, 2013, Brookings vice president Bruce Katz spoke at the Houston convening of the Global Cities Initiative, a joint project of Brookings and JPMorgan Chase to catalyze high-level discussions of metropolitan leadership in the world economy and the actions metro leaders can take to improve trade relationships with cities in mature and rising markets. Hosted by Rice University, the forum brought together distinguished regional, national, and international leaders from the business, civic, government, and philanthropic communities to explore how the greater Houston area can enhance its ability to compete globally.

Bruce Katz - Global Cities Initiative

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Authors

Bruce Katz

Advancing Reform: Medicare Physicians Payments

Kavita Patel — Tue, 14 May 2013 10:00:00 -0400

Chairman Baucus, Ranking Member Hatch and members of the Committee, thank you for this opportunity to highlight ways to advance physician payment reforms in Medicare. The Medicare program retains a strong commitment to provide care to approximately 50 million beneficiaries across the country; a key partner in the provision of this care are the 900,000 healthcare providers who see beneficiaries in medical offices, hospitals, skilled nursing facilities and other settings.[1] Each day, providers work hard to deliver the best care for their patients yet our current payment system falls short time and time again, with financing mechanisms that perpetuate fragmented care and volume over coordination and value. Fortunately, there are better ways to pay physicians that can enable them to improve care, enhance the patient experience and potentially achieve greater savings for the Medicare system overall. I am honored to present some solutions from my work at the Engelberg Center for Health Care Reform at the Brookings Institution and our Merkin Initiative on Clinical Leadership, as a Commissioner on the National Commission on Physician Payment Reform and perhaps most importantly, as a practicing internal medicine physician.[2]

Current Payment Policies in Medicare

Currently, Medicare pays physicians primarily by a fee-for-service (FFS) schedule that is informed by relative value units (RVUs). Relative value units are determined from the Resource Based Relative Value Scale (RBRVS) which defines the value of a service through a calculation of physician work, practice expense and practice liability.[3] A relative value unit is assigned to every medical service that physicians carry out during a clinical visit. [4] The RVU is then adjusted by geographic region (so a procedure performed in Miami, Florida is worth more than a procedure performed in Salem, Oregon). This value is then multiplied by a fixed conversion factor, which changes annually, to determine the amount of payment to the physician. As the number of billable service codes have grown over time, an extensive regulatory process was enacted to develop RVU weights and update them year over year.

Over time, the RVU updating system has placed an increasing importance, evidenced by RVU weights, on procedures, scans, and other technical services that fix certain ailments or problems. Emphasis on technologies and interventions have resulted in a marked disparity between reimbursement for specialties which emphasize procedures such as cardiology and gastroenterology and those that do not such as primary care, endocrinology or infectious diseases, thus exacerbating shortages and the hierarchical culture within medicine.

The 1997 Balanced Budget Act exacerbated the problem with the introduction of the sustainable growth rate or SGR. The SGR was intended to keep the growth in Medicare physician-related spending per beneficiary in line with growth in the nation’s gross domestic product (GDP). In the early years of the SGR, this worked fine, as spending growth was lower than the calculated GDP target and payment rates for physician services increased. But starting with the recession in 2002, spending growth per beneficiary began to exceed GDP growth. In 2002, payment rates were reduced accordingly, by 4.8 percent.

Every year since then, the scheduled SGR payment rate reductions have not taken full effect. Instead, because of concerns about access to care and the sufficiency of payments, Congress has headed off the full payment reductions on a short-term basis. Typically, this has involved offsetting at least some of the budgetary costs with payment reductions affecting other Medicare providers. As Figure 1 illustrates, actual updates as well as the SGR formula update still grow at rates far below input costs (MEI) and payment rates for other providers, thus exacerbating systemic flaws. In short, our system is broken.

Payment Reforms in the Affordable Care Act

The Affordable Care Act included over 100 policy changes in Medicare provider payments, many of which are currently being phased into the current delivery system and affect physicians directly. [5] These reforms include Medicare Accountable Care Organizations (ACOs), Value-based payment modifiers, the Bundled Payments for Care Improvement initiative as well a number of broader efforts for statewide level innovation, multipayer efforts to promote primary care and alignment of payments for Medicare-Medicaid beneficiaries (dual eligibles). These reforms are incredibly effective at encouraging providers to delivery high-quality, coordinated care at a lower cost and enable Medicare to pay for value. As Jonathan Blum, Acting Deputy Administrator and Director of the Center for Medicare recently pointed out in his testimony before this committee, “the Medicare program has been transformed from a passive payer of services into an active purchaser of high-quality, affordable care.” [6] While these reforms will offer a great deal of insight into how we can improve Medicare physician payment through authorities granted in the Patient Protection and Affordable Care Act, they are still largely based on a fee-for-service payment system. We must acknowledge the limitations in implementing payment reforms in the face of a dominant fee-for-service system. One early large-scale Medicare pilot implemented in oncology in 2006 serves as a good example: in conjunction with reductions in Part B drug payments, oncologists received an additional payment to report on whether the chemotherapy care provided by them adhered to certain evidence-based guidelines. This promoted comparisons to the published guidelines and also supported the development of evidence on how widely published guidelines were being followed in practice. [7] However this pilot did not make any changes in the underlying structure of fee-for-service payments and did not explicitly tie payments to measured improvements in performance, resulting in limited feasibility and adoption. In order to move away from our current system and build on the promise of ongoing efforts we must remove the SGR as a constant impediment to true systemic change.

Recommendations of the National Commission on Physician Payment Reform

In an effort to explore new ways that to pay for care that can yield better results for both payers and patients, the Society of General Internal Medicine convened the National Commission on Physician Payment Reform in 2012. Our commission, composed of a broad range of leadership and expertise spanning the public and private sectors, adopted twelve specific recommendations for reforming physician payment:

The SGR adjustment should be eliminated
The transition to an approach based on quality and value should start with the testing of new models of care over a 5-year time period and incorporating them into increasing numbers of practices, with the goal of broad adoption by the end of the decade.
Cost-savings should come from within the Medicare program as a whole. Medicare should where possible, avoid cutting just physician payments to offset the cost of SGR repeal, but should also look for savings from reductions in inappropriate utilization of Medicare services.
The Relative Value Scale Update Committee (RUC) should continue to make changes to become more representative of the medical profession as a whole and to make its decision-making more transparent. CMS has a statutory responsibility to ensure that the relative values it adopts are accurate and appropriate, and therefore it should develop alternative open, evidence-based, and expert processes beyond the recommendations of the RUC to validate the data and methods it uses to establish and update relative values.
For both Medicare and private insurers, annual updates should be increased for evaluation and management codes, which are currently undervalued, and updates for procedural diagnosis codes, which are generally overvalued and thus create incentives for overuse, should be frozen for a period of three years. During this time period, efforts should continue to improve the accuracy of relative values, which may result in some increases as well as some decreases in payments for specific services.
Fee-for-service contracts should always include a component of quality or outcome-based performance reimbursement.
Higher payment for facility-based services that can be performed in a lower cost setting should be eliminated. Additionally, the payment mechanism for physicians should be transparent, and should reimburse physicians roughly equally for equivalent services.
In practices having fewer than five providers, changes in fee-for-service reimbursement should encourage methods for the practices to form virtual relationships and thereby share resources to achieve higher quality care.
Over time, payers should largely eliminate stand-alone fee-for-service payment to physicians because of its inherent inefficiencies and problematic financial incentives.

10. Because fee-for-service will remain an important mode of payment into the future even as the nation shifts to fixed-payment models, future models of physician payment should include appropriate elements of each. Thus, it will be necessary to continue recalibrating fee-for-service payments, even as the nation migrates away from that method of paying physicians.

11. As the nation moves from a fee-for-service system to one that pays physicians through fixed payments, initial payment reforms should focus on areas where significant potential exists for cost savings and higher quality.

12. Measures should be put into place to safeguard access to high quality care, assess the adequacy of risk-adjustment indicators, and promote strong physician commitment to patients.

Moving Beyond the SGR

Eliminating the SGR is a principal recommendation of many expert reports, including our Commission’s Report, MEDPAC, The Brookings Institution, Simpson-Bowles and the Bipartisan Policy Center, but the question remains, repeal and replace with what? [8][9]^,[10]As stated above we (and other clinical groups and societies) recommend a five year transition to newer models of payment which move away from FFS as the dominant payer. But the devil is in the details, and proposals to move towards new models over a period of time leaves policymakers and physicians wondering what their practices will look like next month, next year and beyond. In moving from principle to practice, it is also important to acknowledge that while there will be no one payment model that applies to all physicians, payment models must be relevant to primary care physicians and specialists alike. Additionally, given the growing complexity of caring for Medicare beneficiaries, payment models should encourage collaborations between specialists and primary care physicians rather than focus on a model that is suited for one clinical specialty alone.

Short-Term Steps in Advancing Payment Reforms

To facilitate providers’ transition to alternatives to fee-for-service payments, CMS should harmonize current payment adjustments and quality improvement initiatives and apply those funds towards a care coordination payment which could give physicians more support for broader long-term reform pathways. Medicare has implemented quality reporting systems and payment adjustments for physicians, hospitals, and other providers. But these payments are generally administered as either a flat percentage or adjuster to all FFS payments. In contrast, shifting some existing FFS payments into a care coordination payment would give providers more support in moving toward condition-based, episodic payments, or global payments that allow for management of a population of payments that would otherwise be impossible in the current payment setting.

Table One highlights current efforts within the Medicare to increase value in care; each initiative is important but in isolation results in marginal financial gains and at times and each of these initiatives is limited in scope. For example, quality measures for the Physician Quality Reporting System (PQRS) have flexible annual submission options, with qualification through registries, electronic health records etc. However, the program has suffered from criticism that measures are not as relevant to specialists. And at best, providers will gain approximately an average of $1059 for participation per year, which some might say is not worth the effort, even in a penalty phase of the program. With the passage of the American Taxpayer Relief Act of 2013, a mechanism will be in place by 2014 for specialty specific efforts to satisfy CMS’ reporting requirements for PQRS, which will encourage higher specialist participation in quality improvement efforts and help align clinician-developed quality measures with CMS’ mandate to examine quality of patient care. Applying these measures to help physicians understand how registries can not only benefit their patients but lead to better predictability in a changing payment landscape will facilitate entry into pathways of reform.

Meaningful use measures are also quite detailed with important process metrics but physicians will likely also “perform to the measure” and may have difficulty going beyond unless there are linkages to payment reform. This is reflective of the sentiment that many providers express that they are constantly being asked to measure and perform, all while trying to see just as many patients in a day of work with little to no reward for doing less or changing workflows in order to reduce inappropriate utilization of resources. For example, proposed Stage 2 meaningful use measures include 17 core measures and six additional menu objectives from which a physician would choose at least three. This adds up to a total of 20 distinct actions that often involve all office staff. Rather than adding to these measures, CMS should consider how existing measure components could be applied to a payment update overall or a care coordination payment for the care of a patient with a chronic disease.

In the case of a care coordination payment, providers who opt to enter into a care coordination pathway in the first year can receive a lump sum of payment. This payment would be roughly equivalent to the potential bonus payments for all programs in table one. In return they would have to demonstrate that they are improving clinical practice and implementing outcomes-based clinical measures which are germane to their practice. In this example, a cardiologist would receive a population level care coordination payment derived from bonus payments and some FFS payments who does the following:

Participates in a care coordination pathway for chronic cardiac disease (atrial fibrillation, congestive heart failure, etc)
Subscribes to a cardiac specific registry (thus meeting PQRS requirements)
Implements patient engagement tools for electronic care coordination, medication reminders, therapeutic lab monitoring for anticoagulation (meeting requirements for meaningful use, value-based modifier program, e-prescribing)
Implements a significant practice transformation (potentially a new component which allows for a physician in a small, medium or large practice to individualize their approach to innovation)

The cardiologist would satisfy program requirements and would receive the maximum bonus payments.

Implementing this kind of approach involves potentially supporting CMS and additional entities to provide data on performance measures and quality improvement at more regular intervals along with technical assistance to understand how to translate incoming data into practice transformation. This process can begin in the year following a SGR repeal and can be supported through the assistance of existing clinical societies and quality improvement organizations. In this manner, assumption of clinical and performance risk becomes more commonplace for physicians. Simply put, physicians understand that they need to be held accountable for payment in a standard fashion, but want to feel that they can bring some degree of personalization into their practice in order to meet the needs of their populations.

Finally, I encourage CMS to continue implementing important changes through the Physician Fee Schedule including recent changes for care coordination.[11] These changes are an important acknowledgment that while we migrate from a payment system dominated by fee-for-service, we need to also enhance the existing system to be aligned with the expected outcomes of policy changes. Recent calls for evaluating the distribution of evaluation and management codes and determining the accuracy and appropriate valuation are also an important step in the short term.

Movement from The Short Term to Longer Term Sustainable Payment Reforms

As clinicians of all specialty types realize that there is a viable pathway to care for patients and work across silos. The appetite for a more attractive option is evidenced by the overwhelming response to applications for the CMMI Challenge Grants, BPCI initiative, Medicare Shared Savings Program and other efforts. Clearly, physicians want an alternative.

Through my work at the Brookings Institution’s Engelberg Center for Health Care Reform and the Richard Merkin Initiative on Clinical Leadership, we have been meeting with physicians in primary care and specialties as well as other healthcare stakeholders. With iterative feedback from clinicians in practice, we have proposed a longer term payment model that takes into account the currently uncompensated critical elements of patient care, the need for more flexibility in the way physicians are able to use their time and treatment resources in the best interest of their patients’ individual circumstances, and the need to implement care reforms in a way that recognizes the intense and growing cost pressures in our health care system.

Our model, outlined in Figure 2, would build on the short term payment advances above with incorporation of a payment for care coordination that is derived from the programs in Table One and identify additional opportunities to improve care and lower costs that are not reimbursed well in traditional fee-for-service payment systems. For example, a common procedure in the outpatient cardiac practice is the echocardiogram (echo), or ultrasound of the heart. This procedure is sometimes performed in place of preventive counseling or watchful monitoring of a patient in coordination with a primary care physician, in large part because a hospital-based outpatient cardiology practice receives up to $450 for an echo compared to $53 for a visit without the procedure. Imagine paying both the cardiologist and primary care physician a fixed payment of $400 that allows for longer term communication and conservative monitoring in return for reporting on clinical outcomes at a population level. The clinicians are take the financial risk involved in the clinical care of their patient using the investments previously made by clinically driven pathways, registries and care coordination solutions.

Column A represents total spending on health care and reflects the current state of physician payment: exclusive reliance on the FFS model for physician payments, with waste and inefficiency in the form of redundant and unnecessary care, breakdowns in coordination, escalation of preventable complications etc. This leaves the total cost of physician care high.

Column B illustrates total spending in our alternative payment model. First, a set of services currently reimbursed for a particular episode of care or part of chronic care management are bundled together into a single payment to physicians as a case management payment. For example in clinical oncology a case management payment would include after hours phone care for breast cancer or a palliative care counselor for patients with lung cancer. This enables clinicians to focus less on volume and more on tighter coordination among providers and settings for patients. In addition, we continue the aforementioned care coordination payment paid to physicians, which is built on concepts such as PQRS/ MU and actually increases the current level of physician payment relative to the fee-for-service baseline in Column A. Care coordination payments allow flexibility for physicians to invest in clinical practices and infrastructure through practice transformations that maximizes their ability to treat patients in clinically appropriate ways while not reducing their income due to reductions in billable procedures that would otherwise occur. The investments in clinical practice can include infrastructure/HIT investments or in the case of a small practice, an investment in a shared clinical social worker with other small practices with similar patient populations.

Continuous quality improvement resulting from adherence to clinician-driven process and outcomes measures and the increased flexibility in income will push physicians to decrease and ultimately eliminate the waste and inefficiencies that plague the current system. Overall physician payments increases, offset by reductions in total Medicare spending and system wide savings. Care coordination payments that enhance total physician income tied to quality measures would encourage physicians to collaborate and focus on elements of patient care that reduce cost and inefficiencies across the spectrum. In oncology, for example, we do not specify which metrics should be used in which case but comment that target metrics would change over time and as efficiency is maximized in certain areas of care (i.e. ED visit rates) bonus payments would not cease because of lack of room for improvement. Measures would have to be selected with flexibility to accommodate various provider circumstances and changes in the long term improved performance in certain areas.

Physicians who enter into broader accountable care arrangements in which there is a shared savings component will likely find that this model could lead to an increased proportion of shared savings beyond the 2% threshold; therefore our described model would not be mutually exclusive to ACO arrangements, but could enhance them given the decreased reliance on fee-for-service reimbursement.

Tools that Enable Financial, Clinical and Performance Risk

As I have mentioned earlier, physicians will need tools to better understand risk- these are not lessons we had in medical school or in clinical training. Financial metrics (such as those available to ACOs), performance metrics in the form of actionable and regular data feeds as well as peer-led initiatives should be considered essential components of a payment reform package.

Conclusion

Our nation is in a sustained period of constrained finances and while the cost to repeal the SGR has been decreased to $138 billion, finding the offsets and mechanism to pay for such a solution will not be easy. But it is essential that this Committee seize the opportunity to finally dispel the notion that we allow for a system that rewards the balkanization of our patients through a payment mechanism which promotes volume over value. I commend Senators Baucus and Hatch in their recent call for proposals and specific suggestions from the clinical community and look forward to working with the Committee to identify a tangible path forward. Thank you for this opportunity and I look forward to your questions and comments.

[1] Report to the Congress: Medicare Payment Policy. Medicare Payment Advisory Commission. http://www.medpac.gov/documents/Mar12_EntireReport.pdf

[2] Frist W, Schroeder S, et al. Report of The National Commission on Physician Payment Reform. The National Commission on Physician Payment Reform. http://physicianpaymentcommission.org/wp-content/uploads/2013/03/physician_payment_report.pdf

[3] The RBRVS has three components. Physician work accounts for the time, skill, physical effort, mental judgment and stress involved in providing a service and is approximately 48 percent of the relative value unit. Practice expense refers to the direct costs incurred by the physician and includes the cost of maintaining an office, staff and supplies and accounts for 48 percent. Professional liability insurance takes into account the malpractice insurance essential for maintaining a practice and is 4 percent of the calculation. Overview of the RBRVS. American Medical Association. http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/the-resource-based-relative-value-scale/overview-of-rbrvs.page

^{^[4]}The Centers for Medicare and Medicaid Services (CMS) uses Current Procedural Terminology (CPT) codes to determine services that it will reimburse for Medicare enrollees and each CPT code has an assigned relative value unit.

[5] Policy Options to Sustain Medicare for the Future. January 2013. Kaiser Family Foundation. http://kaiserfamilyfoundation.files.wordpress.com/2013/02/8402.pdf

[6] Statement of Jonathan Blum on Delivery System Reform: Progress Report from CMS Before the Senate Finance Committee. 28 February 2013. Full transcript available at: http://www.finance.senate.gov/imo/media/doc/CMS%20Delivery%20System%20Reform%20Testimony%202.28.13%20(J.%20Blum).pdf

[7] Doherty J, Tanamor M, Feigert J, et al: Oncologists’ Experience in Reporting Cancer Staging and Guideline Adherence: Lessons from the 2006 Medicare Oncology Demonstration. J Oncol Pract. 6(2): 56–59. 2010.

[8] Antos J, Baicker K, McClellan M, et al. Bending the Curve: Person-Centered Health Care Reform. April 2013. Full report here: http://www.brookings.edu/research/reports/2013/04/person-centered-health-care-reform

[9] Bowles E, Simpson A, et al. A Bipartisan Path Forward to Securing America’s Future. Moment of Truth Project. April 2013. Full report available here: http://www.momentoftruthproject.org/sites/default/files/Full%20Plan%20of%20Securing%20America's%20Future.pdf

[10] Daschle T, Domenici P, Frist W, Rivlin A, et al. A Bipartisan Rx for Patient-Centered Care and System-Wide Cost Containment. Bipartisan Policy Center. April 2013. Full report available here: http://bipartisanpolicy.org/sites/default/files/BPC%20Cost%20Containment%20Report.PDF

[11] Bindman A, Blum J, Kronick R. Medicare's Transitional Care Payment — A Step toward the Medical Home.N Engl J Med 2013; 368:692-694

Authors

Kavita Patel

Publication: U.S. Senate Committee on Finance

Sequestration and U.S. Defense Spending: Healing the Wounded Giant

Michael E. O'Hanlon — Mon, 13 May 2013 12:50:00 -0400

Sequestration cuts to the U.S. defense budget have started to affect military contracting and training. Such changes may be fine in the short term, but costly in ways beyond dollar figures in the long term. In his new book Healing the Wounded Giant, Senior Fellow Michael O’Hanlon focuses on the question of how much could be cut from the defense budget if done right. In this video Q&A, O'Hanlon provides examples of two areas where cuts can be made: ground forces and procurement of the F-35 combat jets. He also predicts what Secretary Hagel will propose for the defense budget and how it has the potential to help strike a fiscal deal.

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Sequestration and U.S. Defense Spending: Healing the Wounded Giant

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Michael E. O'Hanlon

The Affordable Care Act and Designing the District of Columbia's Health Benefits Exchange

Alice M. Rivlin — Mon, 13 May 2013 13:59:00 -0400

Before the Health Committee of the District of Columbia Council, Alice Rivlin encourages the Committee to implement the health benefits exchanges of the Affordable Care Act in order to provide universal affordable health care coverage. Explaining that the District has passed tests regarding Medicare and Medicaid, Rivlin describes the District's current health delivery system, explaining the landscape of health care carriers for groups and individuals and recommending that the health exchange become the sole venue for the purchase of individual and small business health insurance.

I am happy to testify on the bill before this Committee, “Better Prices, Better Quality, Better Choices for Health Coverage Amendment Act of 2013,” transmitted by Mayor Vincent C. Gray on behalf of the DC Health Benefit Exchange Authority. I strongly support the bill.

The federal Affordable Care Act (ACA), passed in 2010, is a major step toward an American health care system that covers almost everyone at sustainable cost. Implementation of the ACA is a long-sought opportunity to solve a disgraceful national problem—the fact that a large and growing share of the population cannot afford health insurance—as well as a chance to improve the quality and value of care delivered. As you know, the legislation was controversial at the national level, but the District welcomed it as an opportunity to realize our community’s goal of affordable health care coverage for all.

The District chose to comply with the ACA by creating its own health benefits exchange rather than letting the federal government do it. The District assembled a highly qualified Health Benefit Exchange Board, which recruited a strong professional staff and has implemented the ACA with energy and dispatch. Recently, the District’s exchange passed Phase Two testing with the Centers for Medicare and Medicaid Services. This indicates that the District is expected to be ready to enroll customers on October 1, 2013, and begin coverage on January 1, 2014. We should all be proud of the District for becoming a leader and role model in implementing the ACA, while some States have delayed and are behind schedule.

The exchange will require carriers to compete with one another by displaying qualified plans in transparent form in an electronic market place and allowing consumers to select the best plan for them. Some will receive federal income-tested subsidies to make plans more affordable. This is a win-win: DC residents will receive better health insurance at a lower cost and carriers will sell more insurance policies.

Designing the best exchange for the District has been challenging because DC’s health insurance market is small and highly concentrated. There are only four carriers one of which one controls more than three quarters of the individual and small group markets. The individual market is especially small—in part because of DC’s past success in reducing the number of uninsured residents through generous Medicaid eligibility and the creation of the Alliance. The individual market is estimated to fall below the 100,000 participants that the Urban Institute and others estimate to be the minimum size of the risk pool needed for an exchange to operate efficiently. In view of the small size and high concentration of the market, the DC Health Benefit Authority recommended, and the Council supported, merging the individual and small group markets after a transition period. Merging the markets recognizes that separate exchanges for the individual and small group markets would have too few carriers and too few enrollees to achieve the stability and efficiency that can be achieved in a merged market.

Now the Council is considering whether to make the exchange the sole venue for the purchase of individual and small business health insurance in the District. We believe that this measure will maximize competition, transparency, and the insurance choices available to consumers. Conversely, retaining a separate market outside the exchange will reduce the risk pool below critical size and invite carriers to attempt to attract younger, healthier individuals and employer groups outside the exchange, leaving higher risks in the exchange. In a small market with a dominant insurer, it is essential that the exchange risk pool be as inclusive as possible, both to stabilize the exchange—which is the only source of federal subsidies for District residents with modest incomes—and to maximize transparency and competition.

These design decisions are difficult, but, on balance, it seems wise to require that all DC individual and small business plans be purchased on the exchange with a single risk pool, to allow carriers to offer as many different plans as they want on the exchange, and to work hard to make the exchange as transparent and user friendly as possible. Moreover, the Board’s transition plan carefully balances the goal of full and speedy implementation with the needs of individuals and small business. The transition plan will allow small businesses to enter the health exchange over a two-year transition period, permitting small businesses to wait until the market settles should they feel the need.

Over the past couple of decades DC has gone from a city with a shamefully inadequate health system to a leader in provision of affordable health coverage and improving access to good quality care. We can all take pride in the steps DC has made to take advantage of the opportunity offered by the ACA to move to universal affordable coverage by acting quickly to implement it competently and expeditiously.

Thank you for the opportunity to speak today.

Authors

Alice M. Rivlin

Publication: The Health Committee of the DC Council

The Kampala Convention: Entry Into Force

Chaloka Beyani — Mon, 13 May 2013 09:30:00 -0400

The world’s internally displaced persons (IDPs) number in the tens of millions; the majority of them are in Africa. IDPs are often profoundly vulnerable and must contend with homelessness, hunger, human rights violations and violence. For years, the African Union has sought to help mitigate the plight of IDPs and now with the entry into force of the Kampala Convention, they have formulated and adopted a legally-binding instrument that can do more to help this population. Chaloka Beyani, United Nations Special Rapporteur on the Human Rights of Internally Displaced Persons and co-director of the Brookings-LSE Project on Internal Displacement, says that the convention will also promote good governance, peace, stability and security.

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The Kampala Convention: Entry Into Force

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Chaloka Beyani

Infographic: Should Everyone Go to College?

Isabel V. Sawhill and Stephanie Owen — Wed, 08 May 2013 16:33:00 -0400

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Should Everyone Go To College?

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Isabel V. Sawhill
Stephanie Owen

Subsidizing Higher Education May Not Be Paying Off

Isabel V. Sawhill and Ron Haskins — Tue, 07 May 2013 00:00:00 -0400

A college degree has long been touted as a key component for a successful and prosperous life. But a more critical look reveals that coming in prepared and graduating is often the biggest challenge, especially for disadvantaged students. Senior fellows Isabel Sawhill and Ron Haskins discuss the findings from in the latest issue of The Future of Children journal which is devoted to post secondary education preparation as well as a new Center on Children and Families brief that examines the college return-on-investment.

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Subsidizing Higher Education May Not Be Paying Off

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Improving College Prep. for Low-Income Students

Ron Haskins and Cecilia Elena Rouse — Tue, 07 May 2013 00:00:00 -0400

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Time for Change: A New Federal Strategy to Prepare Disadvantaged Students for College

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Ron Haskins
Cecilia Elena Rouse

Brookings: Latest From Brookings

Confronting Suburban Poverty in America

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Alan Berube

Elizabeth Kneebone

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A Statesman’s Forum with H.E. Recep Tayyip Erdoğan, Prime Minister of Turkey

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The Affordable Care Act: From Hiccups to Repeal

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Federal Tax Reform? Don't Bet The Rent Money On It

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Alleviating Poverty: Mobile Communications, Microfinance and Small Business Development Around the World

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H-1B Visas and the STEM Shortage

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Mapping the African Growth Landscape

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Eyes in the Sky: The Domestic Use of Unmanned Aerial Systems

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GCI Houston: Greater Houston and the Next Economy

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Advancing Reform: Medicare Physicians Payments

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Sequestration and U.S. Defense Spending: Healing the Wounded Giant

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The Affordable Care Act and Designing the District of Columbia's Health Benefits Exchange

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The Kampala Convention: Entry Into Force

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Infographic: Should Everyone Go to College?

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Subsidizing Higher Education May Not Be Paying Off

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Improving College Prep. for Low-Income Students

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