Editor's note: This post originally appeared in the New England Journal of Medicine's Perspective online series on April 22, 2015.

Congress has finally euthanized the sustainable growth rate formula (SGR). Enacted in 1997 and intended to hold down growth of Medicare spending on physician services, the formula initially worked more or less as intended. Then it began to call for progressively larger and more unrealistic fee cuts — nearly 30% in some years, 21% in 2015. Aware that such cuts would be devastating, Congress repeatedly postponed them, and most observers understood that such cuts would never be implemented. Still, many physicians fretted that the unthinkable might happen.

Now Congress has scrapped the SGR, replacing it with still-embryonic but promising incentives that could catalyze increased efficiency and greater cost control than the old, flawed formula could ever really have done, in a law that includes many other important provisions. How did such a radical change occur?  And why now?

The “how” was logrolling — the trading of votes by legislators in order to pass legislation of interest to each of them. Logrolling has become a dirty word, a much-reviled political practice. But the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA), negotiated by House leaders John Boehner (R-OH) and Nancy Pelosi (D-CA) and their staffs, is a reminder that old-time political horse trading has much to be said for it.

The answer to “why now?” can be found in the technicalities of budget scoring. Under the SGR, Medicare’s physician fees were tied through a complex formula to a target based on caseloads, practice costs, and the gross domestic product. When current spending on physician services exceeded the targets, the formula called for fee cuts to be applied prospectively. Fee cuts that were not implemented were carried forward and added to any future cuts the formula might generate. Because Congress repeatedly deferred cuts, a backlog developed. By 2012, this backlog combined with assumed rapid future growth in Medicare spending caused the Congressional Budget Office (CBO) to estimate the 10-year cost of repealing the SGR at a stunning $316 billion.

For many years, Congress looked the costs of repealing the SGR squarely in the eye — and blinked. The cost of a 1-year delay, as estimated by the CBO, was a tiny fraction of the cost of repeal. So Congress delayed — which is hardly surprising.

But then, something genuinely surprising did happen. The growth of overall health care spending slowed, causing the CBO to slash its estimates of the long-term cost of repealing the SGR. By 2015, the 10-year price of repeal had fallen to $136 billion. Even this number was a figment of budget accounting, since the chance that the fee cuts would ever have been imposed was minuscule. But the smaller number made possible the all-too-rare bipartisan collaboration that produced the legislation that President Barack Obama has just signed.

The core of the law is repeal of the SGR and abandonment of the 21% cut in Medicare physician fees it called for this year. In its place is a new method of paying physicians under Medicare. Some elements are specified in law; some are to be introduced later. The hard-wired elements include annual physician fee updates of 0.5% per year through 2019 and 0% from 2020 through 2025, along with a “merit-based incentive payment system” (MIPS) that will replace current incentive programs that terminate in 2018. The new program will assess performance in four categories: quality of care, resource use, meaningful use of electronic health records, and clinical practice improvement activities. Bonuses and penalties, ranging from +12% to –4% in 2020, and increasing to +27% to –9% for 2022 and later, will be triggered by performance scores in these four areas. The exact content of the MIPS will be specified in rules that the secretary of health and human services is to develop after consultation with physicians and other health care providers.

Higher fees will be available to professionals who work in “alternative payment organizations” that typically will move away from fee-for-service payment, cover multiple services, show that they can limit the growth of spending, and use performance-based methods of compensation. These and other provisions will ramp up pressure on physicians and other providers to move from traditional individual or small-group fee-for-service practices into risk-based multi-specialty settings that are subject to management and oversight more intense than that to which most practitioners are yet accustomed.

Both parties wanted to bury the SGR. But MACRA contains other provisions, unrelated to the SGR, that appeal to discrete segments of each party. Democrats had been seeking a 4-year extension of CHIP, which serves 8 million children and pregnant women. They were running into stiff head winds from conservatives who wanted to scale back the program. MACRA extends CHIP with no cuts but does so for only 2 years.  It also includes a number of other provisions sought by Democrats: a 2-year extension of the Maternal, Infant, and Early Childhood Home Visiting program, plus permanent extensions of the Qualified Individual program, which pays Part B Medicare premiums for people with incomes just over the federal poverty thresholds, and transitional medical assistance, which preserves Medicaid eligibility for up to 1 year after a beneficiary gets a job.

The law also facilitates access to health benefits. MACRA extends for two years states’ authority to enroll applicants for health benefits on the basis of data on income, household size, and other factors gathered when people enroll in other programs such as the Supplemental Nutrition Assistance Program, the National School Lunch Program, Temporary Assistance to Needy Families (“welfare”), or Head Start. It also provides $7.2 billion over the next two years to support community health centers, extending funding established in the Affordable Care Act.

Elements of each party, concerned about budget deficits, wanted provisions to pay for the increased spending. They got some of what they wanted, but not enough to prevent some conservative Republicans in both the Senate and the House from opposing final passage. Many conservatives have long sought to increase the proportion of Medicare Part B costs that are covered by premiums. Most Medicare beneficiaries pay Part B premiums covering 25% of the program’s actuarial value. Relatively high-income beneficiaries pay premiums that cover 35, 50, 65, or 80% of that value, depending on their income. Starting in 2018, MACRA will raise the 50% and 65% premiums to 65% and 80%, respectively, affecting about 2% of Medicare beneficiaries. No single person with an income (in 2015 dollars) below $133,501 or couple with income below $267,001 would be affected initially. MACRA freezes these thresholds through 2019, after which they are indexed for inflation. Under previous law, the thresholds were to have been greatly increased in 2019, reducing the number of high-income Medicare beneficiaries to whom these higher premiums would have applied. (For reference, half of all Medicare beneficiaries currently have incomes below $26,000 a year.)

A second provision bars Medigap plans from covering the Part B deductible, which is now $147. By exposing more people to deductibles, this provision will cause some reduction in Part B spending. Everyone who buys such plans will see reduced premiums; some will face increased out-of-pocket costs. The financial effects either way will be small.

Inflexible adherence to principle contributes to the political gridlock that has plunged rates of public approval of Congress to subfreezing lows. MACRA is a reminder of the virtues of compromise and quiet negotiation. A small group of congressional leaders and their staffs crafted a law that gives something to most members of both parties. Today’s appalling norm of poisonously polarized politics make this instance of political horse trading seem nothing short of miraculous.

On June 20, I moderated a conversation on the future of the Department of Veterans Affairs with Secretary Robert McDonald. When he took office almost two years ago, Secretary McDonald inherited an organization in crisis: too many veterans faced shockingly long wait-times before they received care, VA officials had allegedly falsified records, and other allegations of mismanagement abounded.

Photo: Paul Morigi

Since he was sworn into office, Secretary McDonald has led the VA through a period of ambitious reform, anchored by the MyVA program. He and his team have embraced three core strategies that are securing meaningful change. They are important insights for all government leaders, and private sector ones as well.

1. Set bold goals

Secretary McDonald’s vision is for the VA to become the number one customer-service agency in the federal government. But he and his team know that words alone won’t make this happen. They developed twelve breakthrough priorities for 2016 that will directly improve service to veterans. These actionable short-term objectives support the VA’s longer term aim to deliver an exceptional experience for our veterans. By aiming high, and also drafting a concrete roadmap, the VA has put itself on a path to success.

2. Hybridize the best of public and private sectors

To accomplish their ambitious goal, VA leadership is applying the best practices of customer-service businesses around the nation. The Secretary and his colleagues are leveraging the goodwill, resources, and expertise of both the private and public sector. To do that, the VA has brought together diverse groups of business leaders, medical professionals, government executives, and veteran advocates under their umbrella MyVA Advisory Committee. Following the examples set by private sector leaders in service provision and innovation, the VA is developing user-friendly mobile apps for veterans, modernizing its website, and seeking to make hiring practices faster, more competitive, and more efficient. And so that no good idea is left unheard, the VA has created a "shark tank” to capture and enact suggestions and recommendations for improvement from the folks who best understand daily VA operations—VA employees themselves.

3. Data, data, data

The benefits of data-driven decision making in government are well known. As led by Secretary McDonald, the VA has continued to embrace the use of data to inform its policies and improve its performance. Already a leader in the collection and publication of data, the VA has recently taken even greater strides in sharing information between its healthcare delivery agencies. In addition to collecting administrative and health-outcomes information, the VA is gathering data from veterans about what they think . Automated kiosks allow veterans to check in for appointments, and to record their level of satisfaction with the services provided.

The results that the Secretary and his team have achieved speak for themselves:

• 5 million more appointments completed last fiscal year over the previous fiscal year
• 7 million additional hours of care for veterans in the last two years (based on an increase in the clinical workload of 11 percent over the last two years)
• 97 percent of appointments completed within 30 days of the veteran’s preferred date; 86 percent within 7 days; 22 percent the same day
• Average wait times of 5 days for primary care, 6 days for specialty care, and 2 days for mental health are
• 90 percent of veterans say they are satisfied or completely satisfied with when they got their appointment (less than 3 percent said they were dissatisfied or completely dissatisfied).
• The backlog for disability claims—once over 600,000 claims that were more than 125 days old—is down almost 90 percent.

Thanks to Secretary McDonald’s continued commitment to modernization, the VA has made significant progress. Problems, of course, remain at the VA and the Secretary has more work to do to ensure America honors the debt it owes its veterans, but the past two years of reform have moved the Department in the right direction. His strategies are instructive for managers of change everywhere.

Fred Dews and Andrew Kenealy contributed to this post.

“If the Americans and their regional allies want to pass through the Strait of Hormuz and threaten us, we will not allow any entry,” said deputy commander of Iran’s Revolutionary Guards, Hossein Salami, last Wednesday. Iran has a long history of making threats against this critical waterway, through which some 17 million barrels of oil exports pass daily, though it has not carried them out. But multiple regional security threats highlight threats to energy transit from and through the Middle East and North Africa (MENA)—and demand new thinking about solutions.

Weak spots

Hormuz attracts attention because of its evident vulnerability. But recent years have seen severe disruptions to energy flows across the region: port blockades in Libya; pipeline sabotage in Egypt’s Sinai, Yemen, Baluchistan in Pakistan, and Turkey’s southeast; attacks on oil and gas installations across Syria and Iraq; piracy off Somalia. Energy security is threatened at all scales, from local community disturbances and strikes, up to major regional military confrontations.

Of course, it would be best to mitigate these energy security vulnerabilities by tackling the root causes of conflict across the region. But while disruption and violence persist, energy exporters and consumers alike should guard against complacency.

A glut of oil and gas supplies globally—with low prices, growing U.S. self-sufficiency, and the conclusion of the Iranian nuclear deal—may seem to have reduced the urgency: markets have hardly responded to recent flare-ups. But major economies – even the United States – still remain dependent, directly or indirectly, on energy supplies from the MENA region. Spare oil production capacity is at unusually low levels, leaving the balance vulnerable to even a moderate interruption.

Most concern has focused on oil exports, given their importance to the world economy. But the security of liquefied natural gas (LNG) shipments is an under-appreciated risk, particularly for countries such as Japan and South Korea which are heavily dependent on LNG. A disruption would also have severe consequences for countries in the Middle East and North Africa, depriving them not only of revenues but potentially of critical imports.

Doing better 

There are three broad groups of approaches to mitigating the risk of energy transit disruptions: infrastructure, institutions, and market. 

1. Infrastructure includes the construction of bypass pipelines avoiding key choke-points and strategic storage.
   
   Existing bypass pipelines include SUMED (which avoids the Suez Canal); the Habshan-Fujairah pipeline in the UAE (bypassing Hormuz); and the Saudi Petroline, which runs to the Red Sea, hence offering an alternative to the Gulf and Hormuz. Proposed projects include a link from other Gulf Cooperation Council (GCC) countries to Oman’s planned oil terminal at Duqm on the Indian Ocean; new or rehabilitated pipelines from Iraq across Jordan and Turkey; an expansion of Petroline; and a new terminal in southern Iran at Jask.
   
   Strategic storage can be held by oil exporters, by importers, or a combination (in which exporters hold oil close to their customers’ territory, as with arrangements between Saudi Arabia and Japan, and between Abu Dhabi and Japan and India).


2. Institutional approaches include mechanisms to deal with disruptions, such as cooperative sharing arrangements.
   
   More analysis has focused on infrastructure than on institutional and market mitigation. Yet these approaches have to work together. Physical infrastructure is not enough: it has to be embedded in a suitable framework of regulation, legislation, and diplomacy. Cross-border or multilateral pipelines require agreements on international cooperation; strategic storage is most effective when rules for its use are clear, and when holders of storage agree not to hoard scarce supplies. 
   
   The effective combination of infrastructure and institutions has a strategic benefit even if it is never used. By making oil exporters and consumers less vulnerable to threats, it makes it less likely that such threats will be carried out.
   
   Alliances can be useful for mutual security and coordination. However, they raise the difficult question of whom they are directed against. Mutually-hostile alliances would be a threat to regional energy security rather than a guarantor. Organizations such as the International Energy Agency (IEA), the International Energy Forum (IEF), Organization of Petroleum Exporting Countries (OPEC), Gulf Cooperation Council, and the Association of Southeast Asian Nations (ASEAN) could all have roles, but none is ideally placed. Rather than creating another organization, reaching an understanding between existing bodies may be more effective.


3. In general, markets cope well with the task of allocating scarce supplies. Better and timelier data, such as that gathered by the IEF, can greatly improve the functioning of markets. Governments do have a role in protecting the most vulnerable consumers and ensuring sufficient energy for critical services, but price controls, rationing, and export bans have usually been counterproductive, and many of the worst consequences of so-called energy crises have come from well-meaning government interference with the normal market process of adjustment.
   
   However, it is generally difficult or impossible for a single company or country to capture all the benefits of building strategic infrastructure—which, as with a bypass pipeline, may only be required for a few months over a period of decades. International financing, perhaps backed by a major energy importer—mostly likely China—can help support such projects, particularly at a time of fiscal austerity in the Middle East.

Energy exporters within the MENA region may often find their interests divergent. But the field of energy security is one area for more fruitful cooperation—at least between groups of states, and some external players, particularly their increasingly important Asian customers. If regional tensions and conflicts cannot be easily solved, such action at least alleviates one of the serious risks of the region’s turmoil.

For more on this topic, read Robin Mills’ new analysis paper “Risky routes: Energy transit in the Middle East.”

The Venezuelan opposition Movement for Democratic Unity (or MUD by its Spanish acronym) won a major victory over pro-government parties in the December 6 legislative elections. Updated official results show 107 seats for the MUD, 55 for the governing party, 3 representing indigenous communities, with 2 still undecided.

This is remarkable considering the extent to which the government manipulated electoral rules and conditions ahead of the elections. There were a number of reported problems on election day, the most serious of which was to keep polling stations open for up to two additional hours so government supporters could scour voter rolls to find eligible voters who had not yet cast ballots and take them to polling stations. The result was a record 74 percent turnout for legislative elections, with 58 percent voting for the opposition and 42 percent for the government—the mirror image of electoral results in almost all elections since former President Hugo Chávez first took office in 1999. 

In the end, electoral dirty tricks were not enough to prevent an opposition landslide, and President Nicolás Maduro was forced to concede defeat shortly after midnight on December 7. Although the final number of opposition-held seats in the legislature is not yet certain, there are three main questions that should focus our attention over the coming weeks and months:

Venezuela’s legislative election rules are designed to over-represent the majority party and rural areas. This traditionally favored Chavista parties, but in this election, they have given the opposition a boost in the number of seats they won relative to the popular vote. The opposition has already achieved a three-fifths majority, which enables them to pass laws, approve government-proposed budgets, censure and remove government ministers and the executive vice president, and name new appointees to lead the national electoral authority and new magistrates to the Supreme Tribunal. The MUD has already promised to pass an amnesty law for political prisoners aimed at liberating a number of opposition political leaders imprisoned by the Maduro administration. It has also pledged to move legislation designed to promote economic recovery.

The opposition appears to be within striking distance of securing a two-thirds majority (112 seats), which would allow them a much wider array of powers: to remove the existing electoral authorities (with the support of the Supreme Tribunal), submit legislation to approval by popular referendum, and the equivalent of the “nuclear option” for Venezuelan legislators: convene a Constituent Assembly to write a new constitution. But with a few remaining seats in play, it appears that the MUD has more work to do to clear this hurdle and then to maintain discipline among legislators to keep a razor-thin two-thirds majority.

Either way, there is a dangerous gap between the euphoric expectations created by the elections and the actual power of the National Assembly. Not only are legislatures in Latin America typically weak, but the legislative branch has not operated independently thus far during the Chavista period. So many of its potential powers have not been exercised in practice. 

Before the vote, there was a general consensus among analysts that President Maduro would try to limit the power of the legislature in the event of an electoral loss. The tactic has many precedents, with the governments of Presidents Chávez and Maduro previously gutting the power and budgets of opposition-controlled elected offices at state and local levels.

One possibility is that the outgoing Chavista-dominated National Assembly that leaves office in January 2016 will simply pass an enabling law (Ley Habilitante) that would allow President Maduro to rule by decree for the rest of his term. There are plenty of precedents for this in Venezuela, although an enabling law that lasted for the remainder of the presidential term would be exceptional. But others have suggested that given the overwhelming opposition victory, such an approach may run too blatantly contrary to public opinion and consolidate popular sentiment against the government.

Instead, the government may simply use the Supreme Tribunal to invalidate opposition-initiated legislation. Of the 32 magistrates appointed to the highest court in Venezuela, 13 judges are retiring. Together with 5 empty seats, that will allow the outgoing legislative assembly to approve 18 new judges. These will join 12 magistrates appointed by the Chavista-controlled legislature in December 2014. With the government appointing so many members of the Supreme Tribunal, it will likely be easy for the Maduro administration to block inconvenient legislative proposals. The question for the opposition then becomes whether it can figure out how to use control of the legislature to affect the composition of the court and dilute the power of pro-government magistrates, something that would undoubtedly set off a struggle among the various branches of government.

It seems unlikely that the Chavista movement will simply accept divided government, something unknown to Venezuela since 1999. There are simply too many in the Chavista movement who cannot afford an “accountability moment” due to alleged participation in official corruption; waste, fraud, and abuse; or drug trafficking. Others will be ideologically opposed to allowing so much power to flow to an opposition-dominated national assembly.

The Chavista movement spans from the military to the governing party to armed pro-government militias and gangs (colectivos). Former President Chávez was adept at keeping the movement together. President Maduro is not nearly as skilled, and with this stunning electoral loss, his leadership within the movement (already damaged by poor economic results) is likely to come under further pressure. 

In a normal country, one might imagine some incentives for both sides to negotiate—the legislature and executive could work together to avert the coming economic catastrophe, for one. And the weakening of President Maduro’s leadership may lead to more open disagreement within Chavismo about the way ahead, allowing the possibility that moderates on both sides will find room to work together. But as journalist and long-time Venezuela observer Francisco Toro has argued, Chavismo is a machine for not negotiating; the selection process for top leadership has been designed to winnow out anyone who would consider sitting down to talk with the opposition. And in such a polarized situation, moderates always run the risk of being targeted by radicals from their own side if they negotiate with opponents.

Get the house in order

All Venezuelans should feel proud (and relieved) that these highly significant elections have been carried out peacefully. But a lot of work remains to be done. 

First, the outside study missions and electoral accompaniment missions need to remain focused on the tabulation process to ensure that the few undecided legislative seats are allocated according to electoral rules and the votes cast rather than government fiat. 

Second, Venezuela is entering a period of divided government, one that will potentially be riven by conflict among the branches of government. The outside actors that have thus far played a positive role—such as regional multilateral institutions, civil society, legislators across the hemisphere, and governments interested in supporting democracy—will need to continue to pay attention to and support favorable outcomes in Venezuela even when the country is out of the international headlines. 

And third, Venezuela’s economy is in very serious trouble now that oil has fallen as low as $35 a barrel. Further economic contraction, poverty rates not seen since before Hugo Chávez took office, and inflation in excess of 200 percent are all expected in 2016. If the government (both Chavistas and opponents) come to their senses and agree to a negotiated plan on how to address the economy, they will need the support of both traditional multilateral financial institutions and non-traditional sources of financing (such as China). 

As the opposition celebrates this major electoral win, it will undoubtedly dwell on the political implications of its victory over Chavismo. But it should not lose sight of the mandate it has now been given to make needed policy changes as well.

Update: As of December 9, 2015, media are reporting that the opposition party has won at least 112 seats, achieving a two-thirds majority in the National Assembly.

For nearly fifteen hours between Wednesday morning and early Thursday, Senator Chris Murphy (D-CT), along with his Connecticut colleague Senator Richard Blumenthal (D) and Senator Cory Booker (D-NJ), led a filibuster on the floor of the Senate aimed at addressing gun control issues in the aftermath of last weekend’s mass shooting in Orlando. Other than learning that Wednesday is pizza night in the Murphy household, what else should we take away from this Mr. Smith Goes to Washington­-style exercise? Here are three lessons:

1. The real meaning of “I” in “I hold the floor until I yield the floor.”

Anyone who tuned into yesterday’s filibuster joined Senate procedure wonks (and faithful viewers of the West Wing) in the knowledge that a senator who holds the floor can yield to another senator for a question without yielding the floor. Indeed, 38 of Murphy’s 45 Democratic colleagues (as well as two Republicans, Senators Ben Sasse (R-NE) and Pat Toomey (R-PA)), came to the chamber yesterday to ask “questions.” In many cases, these were lengthy speeches—Senator Tammy Baldwin (D-WI), for example, read brief biographies of all 49 Orlando victims—in which the speaker satisfied the question requirement with a conclusion that asked Murphy for his reactions to their statement.

This kind of teamwork on extended speech-making is not unusual. When Senator Ted Cruz (R-TX) took the floor to talk for 21 hours about the Affordable Care Act in 2013, he took questions from nine fellow Republicans (as well as two Democrats). Last May, Senator Rand Paul (R-KY) got an assist from ten colleagues, including seven Democrats, during his filibuster of a bill extending the PATRIOT Act. The depth of Murphy’s bench not only reduced the energy he had to expend speaking, but also helped guarantee that the entire discussion was on-message and focused on the topic at hand; Murphy did not have to resort to reading the phone book to fill the hours.

2. In policy terms, it’s hard to know if the filibuster was a success…

When Murphy left the floor early Thursday morning, it was reported that Senate leaders had agreed to consider two gun control amendments: one that would address the ability of suspected terrorists to purchase guns and a second that would expand background checks for gun purchases. Details of the deal ensuring consideration are still emerging, but it is difficult to know if Murphy’s filibuster caused Senate leaders to agree to hold votes on them. It is possible that, had Democrats simply threatened to object to the motion to proceed to debate on the underlying spending bill, Republican leaders would have been forced to agree to consider the amendments for which Murphy and his allies were pushing. In the contemporary Senate, this is often how obstruction proceeds: without extended speeches and off the floor, with the two sides negotiating behind the scenes.

3. …but the political victory is perhaps more important

As my colleague Sarah Binder and her co-author Steve Smith wrote in their 1997 book on the filibuster, “encouragement from external groups…has given senators an incentive to exploit their procedural rights, sometimes leading them to block legislation with the filibuster or with holds and at other times leading them to use procedural prerogatives to force the Senate to consider issues of importance to parochial, partisan, or national constituencies.” On these grounds, Murphy’s filibuster was unequivocally a success in the eyes of its supporters. As the filibuster neared its end, Murphy reported that his office had received 10,000 phone calls supporting his efforts, and the hashtag #filibuster was trending on Twitter for much of the day. Even if the underlying amendments are not adopted—a real possibility that Murphy acknowledged in one of his final speeches of the evening—the visibility of the exercise is likely to pay political dividends for Democrats in the coming weeks.

"We are now locked in a rolling filibuster on every issue, which is totally gridlocking the U.S. Senate. That is wrong. It is wrong for America."

Who said that? Democrat Harry Reid, majority leader of the Senate? Guess again. Try former Republican leader Trent Lott, bemoaning the troubled state of the Senate in the late 1990s.

No recent majority leader of either party has been saved the headache of trying to lead a Senate in which minorities can exploit the rules and stymie the chamber. This is not a new problem. Harry Reid may face a particularly unrestrained minority. But generations of Senate leaders from Henry Clay to Bill Frist have felt compelled to seek changes in Senate rules to make the chamber a more governable place.

Some things never change.

Twice this week, the Senate has opened debate with its party leaders engaged in a caustic battle over Reid's plans to seek changes to Senate rules in January.

Read the full piece at CNN.com »