The Center for Medicare and Medicaid Innovation (CMMI, or “the Innovation Center”) recently announced an initiative called Comprehensive Primary Care Plus (CPC+). It evolved from the Comprehensive Primary Care (CPC) initiative, which began in 2012 and runs through the end of this year. Both initiatives are designed to promote and support primary care physicians in organizing their practices to deliver comprehensive primary care services. Comprehensive Primary Care Plus has some very promising components, but also misses some compelling opportunities to further advance payment for primary care services.

The earlier initiative, CPC, paid qualified primary care practices a monthly fee per Medicare beneficiary to support practices in making changes in the way they deliver care, centered on five comprehensive primary care functions: (1) access and continuity; (2) care management; (3) comprehensiveness and coordination; (4) patient and caregiver engagement; and, (5) planned care and population health. For all other care, regular fee-for-service (FFS) payment continued. The initiative was limited to seven regions where CMMI could reach agreements with key private insurers and the Medicaid program to pursue a parallel approach. The evaluation funded by CMMI found quality improvements and expenditure reductions, but savings did not cover the extra payments to practices.

Comprehensive Primary Care Plus uses the same strategy of conducting the experiment in regions where key payers are pursuing parallel efforts. In these regions, qualifying primary care practices can choose one of two tracks. Track 1 is very similar to CPC. The monthly care management fee per beneficiary remains the same, but an extra $2.50 is paid in advance, subject to refund to the government if a practice does not meet quality and utilization performance thresholds.

The Promise Of CPC+

Track 2, the more interesting part of the initiative, is for practices that are already capable of carrying out the primary care functions and are ready to increase their comprehensiveness. In addition to a higher monthly care management fee ($28), practices receive Comprehensive Primary Care Payments. These include a portion of the expected reimbursements for Evaluation and Management services, paid in advance, and reduced regular fee-for-service payments. Track 2 also includes larger rewards than does Track 1 for meeting performance thresholds.

The combination of larger per beneficiary monthly payments and lower payments for services is the most important part of the initiative. By blending capitation (monthly payments not tied to service volume) and FFS, this approach might achieve the best of both worlds.

Even when FFS payment rates are calibrated correctly (discussed below), the rates are pegged to the average costs across practices. But since a large part of practice cost is fixed, it means that the marginal cost of providing additional services is lower than the average cost, leading to incentives to increase volume under FFS. The lower payments reduce or eliminate these incentives. Fixed costs, which must also be covered, are addressed through the Comprehensive Primary Care Payments. By involving multiple payers, practices are put in a better position to pursue these changes.

An advantage of any program that increases payments to primary care practices is that it can partially compensate for a flaw in the relative value scale behind the Medicare physician fee schedule. This flaw leads to underpayment for primary care services. Although the initial relative value scale implemented in 1992 led to substantial redistribution in favor of evaluation and management services and to physicians who provide the bulk of them, a flawed update process has eroded these gains over the years to a substantial degree.

In response to legislation, the Centers for Medicare and Medicaid Services are working correct these problems, but progress is likely to come slowly. Higher payments for primary care practices through the CPC+ can help slow the degree to which physicians are leaving primary care until more fundamental fixes are made to the fee schedule. Indeed, years of interviews with private insurance executives have convinced us that concern about loss of the primary care physician workforce has been a key motivation for offering higher payment to primary care physicians in practices certified as patient centered medical homes.

Two Downsides

But there are two downsides to the CPC+.

One concerns the lack of incentives for primary care physicians to take steps to reduce costs for services beyond those delivered by their practices. These include referring their patients to efficient specialists and hospitals, as well as limiting hospital admissions. There are rewards in CPC+ for lower overall utilization by attributed beneficiaries and higher quality, but they are very small.

We had hoped that CMMI might have been inspired by the promising initiatives of CareFirst Blue Cross Blue Shield and the Arkansas Health Care Improvement initiative, which includes the Arkansas Medicaid program and Arkansas Blue Cross Blue Shield. Under those programs, primary care physicians are offered substantial bonuses for keeping spending for all services under trend for their panel of patients; there is no downside risk, which is understandable given the small percentage of spending accounted for by primary care. The private and public payers also support the primary care practices with care managers and with data on all of the services used by their patients and on the efficiency of providers they might refer to. These programs appear to be popular with physicians and have had promising early results.

The second downside concerns the inability of physicians participating in CPC+ to participate in accountable care organizations (ACOs). One of CMMI’s challenges in pursuing a wide variety of payment innovations is apportioning responsibility across the programs for beneficiaries who are attributed to multiple payment reforms. As an example, if a beneficiary attributed to an ACO has a knee replacement under one of Medicare’s a bundled payment initiatives, to avoid overpayment of shared savings, gains or losses are credited to the providers involved in the bundled payment and not to the ACO. As a result, ACOs are no longer rewarded for using certain tools to address overall spending, such as steering attributed beneficiaries to efficient providers for an episode of care or encouraging primary care physicians to increase the comprehensiveness of the care they deliver.

Keeping the physician participants in CPC+ out of ACOs altogether seems to be another step to undermine the potential of ACOs in favor of other payment approaches. This is not wise. The Innovation Center has appropriately not established a priority ranking for its various initiatives, but some of its actions have implicitly put ACOs at the bottom of the rankings. Recently, Mostashari, Kocher, and McClellan proposed addressing this issue by adding a CPC+ACO option to this initiative.

In an update to its FAQ published May 27, 2016 (after out blog was put into final form), CMMI eased its restriction somewhat by allowing up to 1,500 of the 5000 practices expected to participate in CPC+ to also participate in Medicare Shared Savings Program (MSSP) ACOs. But the prohibition continues to apply to Next Gen ACOs, the model that has created the most enthusiasm in the field. If demand for these positions in MSSP ACOs exceeds 1,500, a lottery will be held. This change is welcome but does not really address the issue of disadvantaging ACOs in situations where a beneficiary is attributed to two or more payment reform models. CMMI is sending a signal that CPC+, notwithstanding its lack of incentives concerning spending outside of primary care, is a powerful enough reform that diverting practices away from ACOs is not a problem. ACOs are completely dependent on primary care physician membership to function, meaning that any physician practices beyond 1,500 that enroll in CPC+ will reduce the size and the impact of the ACO program. CMMI has never published a priority ranking of reform models, but its actions keep indicating that ACOs are at the bottom.

The Innovation Center should be lauded for continuing to support improved payment models for primary care. Its blending of substantial monthly payments with lower payments per service is promising. But the highest potential rewards come from broadening primary care physicians’ incentives to include the cost and quality of services by other providers. CMMI should pursue this approach.

Editor's note: This piece originally appeared in Health Affairs Blog.

On his fourth trip to the U.S. as Indian Prime Minister, Narendra Modi will spend some quality time on Capitol Hill on Wednesday, where he'll address a joint meeting of the U.S. Congress. House Speaker Paul Ryan will also host the Indian premier for a lunch, which will be followed by a reception hosted jointly by the House and Senate Foreign Relations Committees and the India Caucus. What's the significance of this Congressional engagement and what might be Modi's message? 

Given that all the most-recent Indian leaders who've held five-year terms have addressed such joint meetings of Congress, some have asked whether Ryan's invitation to Modi is a big deal. The answer is, yes, it is an honour and not one extended all that often. Since 1934, there have been only 117 such speeches. Leaders from France, Israel and the United Kingdom have addressed joint meetings the most times (8 each), followed by Mexico (7), and Ireland, Italy and South Korea (6 each). With this speech, India will join Germany on the list with leaders having addressed 5 joint meetings of Congress: Rajiv Gandhi in 1985, P.V. Narashima Rao in 1994, Atal Bihari Vajpayee in 2000 and Manmohan Singh in 2005. India's first premier, Jawaharlal Nehru, spoke to the House and Senate in separate back-to-back sessions in 1949 as well. 

Congress is a key stakeholder in the U.S.-India relationship and can play a significant supportive or spoiler role. While American presidents have a lot more lee-way on foreign policy than domestic policy, Congress is not without influence on U.S. foreign relations, and shapes the context for American engagement abroad. Moreover, the breadth and depth of the U.S.-India relationship, as well as the blurring of the line between what constitutes domestic and foreign policy these days means that India's options can be affected by American legislative decisions or the political mood on a range of issues from trade to immigration, energy to defense. 

The Indian Foreign Secretary recently said that the U.S. legislature was at "very much at the heart" of the relationship today. He noted it has been "very supportive" and "even in some more difficult days where actually the Congress has been the part of the US polity which has been very sympathetic to India." But India's had rocky experiences on the Hill as well--which only heightens the need to engage members of Congress at the highest levels. 

The speech and the other interactions offer Modi an opportunity to acknowledge the role of Congress in building bilateral relations, highlight shared interests and values, outline his vision for India and the relationship, as well as tackle some Congressional concerns and note some of India's own. He'll be speaking to multiple audiences in Congress, with members there either because of the strategic imperative for the relationship, others because of the economic potential, yet others because of the values imperative--and then there are those who'll be there because it is important to their constituents, whether business or the Indian diaspora. There is also the audience outside Congress, including in India, where the speech will play in primetime. What will Modi's message be? A glimpse at previous speeches might offer some clues, though Modi is likely also to want to emphasize change. 

The speeches that came before

The speeches of previous prime ministers have addressed some common themes. They've acknowledged shared democratic values. They've mentioned the two-way flow of inspiration and ideas with individuals like Henry David Thoreau, Mahatma Gandhi, Martin Luther King getting multiple mentions. They've noted the influence of American founding documents or fathers on the Indian constitution. They've highlighted India's achievements, while stressing that much remains to be done. 

They've noted their country's diversity, and the almost-unique task Indian leaders have had--to achieve development for hundreds of millions in a democratic context. Since Gandhi, each has mentioned the Indian diaspora, noting its contributions to the U.S. Each prime minister has also expressed gratitude for American support or the contribution the U.S. partnership has made to India's development and security. They've acknowledged differences, without dwelling on them. They've addressed contemporary Congressional concerns that existed about Indian policy--in some cases offering a defense of them, in others' explaining the reason behind the policy.

Many of the premiers called for Congress to understand that India, while a democracy like the U.S. and sharing many common interests, would not necessarily achieve its objectives the same way as the U.S. And each subtly has asked for time and space, accommodation and support to achieve their goals--and argued it's in American interests to see a strong, stable, prosperous, democratic India.

In terms of subjects, each previous speech has mentioned economic growth and development as a key government priority, highlighting what policymakers were doing to achieve them. Since Gandhi, all have mentioned nuclear weapons though with different emphases: he spoke of disarmament; Rao of de-nuclearization and concerns about proliferation; two years after India's nuclear test, Vajpayee noted India's voluntary moratorium on testing and tried to reassure Congress about Indian intentions; and speaking in the context of the U.S.-India civil nuclear talks, Singh noted the importance of civil nuclear energy and defended India's track record on nuclear non-proliferation.

Since Rao, every prime minister has mentioned the challenge that terrorism posed for both the U.S. and India, with Vajpayee and Singh implicitly noting the challenge that a neighboring country poses in this regard from India's perspective. And Rao and Singh made the case for India to get a permanent seat on the U. N. Security Council.

The style of the speeches has changed, as has the tone. Earlier speeches were littered with quotes from sources like Christopher Columbus, Swami Vivekananda, Abraham Lincoln, Lala Lajpat Rai and the Rig Veda. Perhaps that was reflective of the style of speechwriting in those eras, but perhaps it was also because there were fewer concrete issues in the bilateral relationship to address. The evolution in the areas of cooperation is evident in the speeches. 

Rao's speech about two decades ago, for instance, listed U.S.-India common interests as peacekeeping, environmental crises, and combating international terrorism and international narcotics trafficking. Compare that to Singh's address which talked of cooperation on a range of issues from counterterrorism, the economy, agriculture, energy security, healthy policy, humanitarian assistance and disaster relief (HADR), democracy promotion, and global governance.

The speech yet to come

Modi will likely strike some similar themes, acknowledging the role that the U.S. Congress has played in shaping the relationship and expressing gratitude for its support. Like Vajpayee, particularly in a U.S. election year, Modi might note the bipartisan support the relationship has enjoyed in recent years. He'll undoubtedly talk about shared democratic values in America's "temple of democracy"--a phrase he used for the Indian parliament when he first entered it after his 2014 election victory. Modi will not necessarily mention the concerns about human rights, trade and investment policies, non-proliferation or India's Iran policy that have arisen on the Hill, but he will likely address them indirectly. 

For example, by emphasizing India's pluralism and diversity and the protection its Constitution gives to minorities, or the constructive role the country could play regionally (he might give examples such as the recently inaugurated dam in Afghanistan). Given the issues on the bilateral agenda, he'll likely mention the strategic convergence, his economic policy plans, terrorism, India's non-proliferation record, defense and security cooperation, and perhaps--like Vajpayee--the Asia-Pacific (without directly mentioning China). And like Vajpayee, he might be more upfront about Indian concerns and the need to accommodate them. 

While he might strike some similar themes as his predecessors and highlight aspects of continuity, Modi will also want to emphasize that it's not business as usual. He'll likely try to outline the change that he has brought and wants to bring. In the past, he has noted the generational shift that he himself represents as the first Indian prime minister born after independence and the Modi government's latest tag line is, of course, "Transforming India." And he might emphasize that this changed India represents an opportunity for the U.S.

He won't wade directly into American election issues, but might note the importance of U.S. global engagement. He might also try to address some of the angst in the U.S. about other countries taking advantage of it and being "takers." He could do this by making the case that India is not a free rider--that through its businesses, market, talent and diaspora it is contributing to American economy and society, through its economic development it will contribute to global growth, and through Indian prosperity, security and a more proactive international role--with a different approach than another Asian country has taken--it'll contribute to regional stability and order. He might also suggest ways that the U.S. can facilitate India playing such a role.

Unlike previous leaders, he has not tended to appeal to others not to ask India to do more regionally and globally because it's just a developing country and needs to focus internally. The Modi government has been highlighting the contributions of India and Indians to global and regional peace and prosperity--through peacekeeping, the millions that fought in the World Wars, HADR operations in its neighborhood, evacuation operations in Yemen in which it rescued not just Indian citizens, but Americans as well.

His government has been more vocal in joint contexts of expressing its views on the importance of a rules-based order in the Asia-Pacific and Indian Ocean regions--and we might hear more on this in his address. Overall, a theme will likely be that India is not just a "taker," and will be a responsible, collaborative stakeholder.

It'll be interesting to see whether the Indian prime minister notes the role that his predecessors have played in getting the relationship to this point. With some exceptions--for example, he acknowledged Manmohan Singh's contribution during President Obama's visit to India last year--he has not tended to do so. But there's a case to be made for doing so--it can reassure members of Congress that the relationship transcends one person or party and is based on a strategic rationale, thus making it more sustainable. Such an acknowledgement could be in the context of noting that it's not just Delhi and Washington that have built and are building this relationship, but the two countries' states, private sectors, educational institutions and people. 

This wouldn't prevent Modi from highlighting the heightened intensity of the last two years, particularly the progress in defense and security cooperation. (From a more political perspective, given that there has been criticism in some quarters of India-U.S. relations becoming closer, it can also serve as a reminder that the Congress party-led government followed a similar path).

Modi will be competing for media attention in the U.S. thanks to the focus in the U.S. on the Democratic primaries this week, but he'll have Congressional attention. But it's worth remembering that Indian prime ministers have been feted before, but if they don't deliver on the promise of India and India-U.S. relations that they often outline, disillusionment sets in. Modi will have to convince them that India is a strategic bet worth making--one that will pay off.

This piece was originally published by Huffington Post India.

On his fourth trip to the U.S. as Indian Prime Minister, Narendra Modi will spend some quality time on Capitol Hill on Wednesday, where he'll address a joint meeting of the U.S. Congress. House Speaker Paul Ryan will also host the Indian premier for a lunch, which will be followed by a reception hosted jointly by the House and Senate Foreign Relations Committees and the India Caucus. What's the significance of this Congressional engagement and what might be Modi's message? 

Given that all the most-recent Indian leaders who've held five-year terms have addressed such joint meetings of Congress, some have asked whether Ryan's invitation to Modi is a big deal. The answer is, yes, it is an honour and not one extended all that often. Since 1934, there have been only 117 such speeches. Leaders from France, Israel and the United Kingdom have addressed joint meetings the most times (8 each), followed by Mexico (7), and Ireland, Italy and South Korea (6 each). With this speech, India will join Germany on the list with leaders having addressed 5 joint meetings of Congress: Rajiv Gandhi in 1985, P.V. Narashima Rao in 1994, Atal Bihari Vajpayee in 2000 and Manmohan Singh in 2005. India's first premier, Jawaharlal Nehru, spoke to the House and Senate in separate back-to-back sessions in 1949 as well. 

Congress is a key stakeholder in the U.S.-India relationship and can play a significant supportive or spoiler role. While American presidents have a lot more lee-way on foreign policy than domestic policy, Congress is not without influence on U.S. foreign relations, and shapes the context for American engagement abroad. Moreover, the breadth and depth of the U.S.-India relationship, as well as the blurring of the line between what constitutes domestic and foreign policy these days means that India's options can be affected by American legislative decisions or the political mood on a range of issues from trade to immigration, energy to defense. 

The Indian Foreign Secretary recently said that the U.S. legislature was at "very much at the heart" of the relationship today. He noted it has been "very supportive" and "even in some more difficult days where actually the Congress has been the part of the US polity which has been very sympathetic to India." But India's had rocky experiences on the Hill as well--which only heightens the need to engage members of Congress at the highest levels. 

The speech and the other interactions offer Modi an opportunity to acknowledge the role of Congress in building bilateral relations, highlight shared interests and values, outline his vision for India and the relationship, as well as tackle some Congressional concerns and note some of India's own. He'll be speaking to multiple audiences in Congress, with members there either because of the strategic imperative for the relationship, others because of the economic potential, yet others because of the values imperative--and then there are those who'll be there because it is important to their constituents, whether business or the Indian diaspora. There is also the audience outside Congress, including in India, where the speech will play in primetime. What will Modi's message be? A glimpse at previous speeches might offer some clues, though Modi is likely also to want to emphasize change. 

The speeches that came before

The speeches of previous prime ministers have addressed some common themes. They've acknowledged shared democratic values. They've mentioned the two-way flow of inspiration and ideas with individuals like Henry David Thoreau, Mahatma Gandhi, Martin Luther King getting multiple mentions. They've noted the influence of American founding documents or fathers on the Indian constitution. They've highlighted India's achievements, while stressing that much remains to be done. 

They've noted their country's diversity, and the almost-unique task Indian leaders have had--to achieve development for hundreds of millions in a democratic context. Since Gandhi, each has mentioned the Indian diaspora, noting its contributions to the U.S. Each prime minister has also expressed gratitude for American support or the contribution the U.S. partnership has made to India's development and security. They've acknowledged differences, without dwelling on them. They've addressed contemporary Congressional concerns that existed about Indian policy--in some cases offering a defense of them, in others' explaining the reason behind the policy.

Many of the premiers called for Congress to understand that India, while a democracy like the U.S. and sharing many common interests, would not necessarily achieve its objectives the same way as the U.S. And each subtly has asked for time and space, accommodation and support to achieve their goals--and argued it's in American interests to see a strong, stable, prosperous, democratic India.

In terms of subjects, each previous speech has mentioned economic growth and development as a key government priority, highlighting what policymakers were doing to achieve them. Since Gandhi, all have mentioned nuclear weapons though with different emphases: he spoke of disarmament; Rao of de-nuclearization and concerns about proliferation; two years after India's nuclear test, Vajpayee noted India's voluntary moratorium on testing and tried to reassure Congress about Indian intentions; and speaking in the context of the U.S.-India civil nuclear talks, Singh noted the importance of civil nuclear energy and defended India's track record on nuclear non-proliferation.

Since Rao, every prime minister has mentioned the challenge that terrorism posed for both the U.S. and India, with Vajpayee and Singh implicitly noting the challenge that a neighboring country poses in this regard from India's perspective. And Rao and Singh made the case for India to get a permanent seat on the U. N. Security Council.

The style of the speeches has changed, as has the tone. Earlier speeches were littered with quotes from sources like Christopher Columbus, Swami Vivekananda, Abraham Lincoln, Lala Lajpat Rai and the Rig Veda. Perhaps that was reflective of the style of speechwriting in those eras, but perhaps it was also because there were fewer concrete issues in the bilateral relationship to address. The evolution in the areas of cooperation is evident in the speeches. 

Rao's speech about two decades ago, for instance, listed U.S.-India common interests as peacekeeping, environmental crises, and combating international terrorism and international narcotics trafficking. Compare that to Singh's address which talked of cooperation on a range of issues from counterterrorism, the economy, agriculture, energy security, healthy policy, humanitarian assistance and disaster relief (HADR), democracy promotion, and global governance.

The speech yet to come

Modi will likely strike some similar themes, acknowledging the role that the U.S. Congress has played in shaping the relationship and expressing gratitude for its support. Like Vajpayee, particularly in a U.S. election year, Modi might note the bipartisan support the relationship has enjoyed in recent years. He'll undoubtedly talk about shared democratic values in America's "temple of democracy"--a phrase he used for the Indian parliament when he first entered it after his 2014 election victory. Modi will not necessarily mention the concerns about human rights, trade and investment policies, non-proliferation or India's Iran policy that have arisen on the Hill, but he will likely address them indirectly. 

For example, by emphasizing India's pluralism and diversity and the protection its Constitution gives to minorities, or the constructive role the country could play regionally (he might give examples such as the recently inaugurated dam in Afghanistan). Given the issues on the bilateral agenda, he'll likely mention the strategic convergence, his economic policy plans, terrorism, India's non-proliferation record, defense and security cooperation, and perhaps--like Vajpayee--the Asia-Pacific (without directly mentioning China). And like Vajpayee, he might be more upfront about Indian concerns and the need to accommodate them. 

While he might strike some similar themes as his predecessors and highlight aspects of continuity, Modi will also want to emphasize that it's not business as usual. He'll likely try to outline the change that he has brought and wants to bring. In the past, he has noted the generational shift that he himself represents as the first Indian prime minister born after independence and the Modi government's latest tag line is, of course, "Transforming India." And he might emphasize that this changed India represents an opportunity for the U.S.

He won't wade directly into American election issues, but might note the importance of U.S. global engagement. He might also try to address some of the angst in the U.S. about other countries taking advantage of it and being "takers." He could do this by making the case that India is not a free rider--that through its businesses, market, talent and diaspora it is contributing to American economy and society, through its economic development it will contribute to global growth, and through Indian prosperity, security and a more proactive international role--with a different approach than another Asian country has taken--it'll contribute to regional stability and order. He might also suggest ways that the U.S. can facilitate India playing such a role.

Unlike previous leaders, he has not tended to appeal to others not to ask India to do more regionally and globally because it's just a developing country and needs to focus internally. The Modi government has been highlighting the contributions of India and Indians to global and regional peace and prosperity--through peacekeeping, the millions that fought in the World Wars, HADR operations in its neighborhood, evacuation operations in Yemen in which it rescued not just Indian citizens, but Americans as well.

His government has been more vocal in joint contexts of expressing its views on the importance of a rules-based order in the Asia-Pacific and Indian Ocean regions--and we might hear more on this in his address. Overall, a theme will likely be that India is not just a "taker," and will be a responsible, collaborative stakeholder.

It'll be interesting to see whether the Indian prime minister notes the role that his predecessors have played in getting the relationship to this point. With some exceptions--for example, he acknowledged Manmohan Singh's contribution during President Obama's visit to India last year--he has not tended to do so. But there's a case to be made for doing so--it can reassure members of Congress that the relationship transcends one person or party and is based on a strategic rationale, thus making it more sustainable. Such an acknowledgement could be in the context of noting that it's not just Delhi and Washington that have built and are building this relationship, but the two countries' states, private sectors, educational institutions and people. 

This wouldn't prevent Modi from highlighting the heightened intensity of the last two years, particularly the progress in defense and security cooperation. (From a more political perspective, given that there has been criticism in some quarters of India-U.S. relations becoming closer, it can also serve as a reminder that the Congress party-led government followed a similar path).

Modi will be competing for media attention in the U.S. thanks to the focus in the U.S. on the Democratic primaries this week, but he'll have Congressional attention. But it's worth remembering that Indian prime ministers have been feted before, but if they don't deliver on the promise of India and India-U.S. relations that they often outline, disillusionment sets in. Modi will have to convince them that India is a strategic bet worth making--one that will pay off.

This piece was originally published by Huffington Post India.

In a rare Kumbaya moment, the nation's leaders of both parties have decided that rebate checks and a flurry of other short-term measures are needed to help stave off an economic slowdown.

Unfortunately, but predictably, we're hearing far less from Capitol Hill and the campaign trail about the bigger picture and the long-term challenges facing the American economy.

Increasing competition from nations like China and India, the impending retirements of the baby boomers, and the highly unequal distribution of benefits from the recent expansion all signal the potential for slower U.S. economic growth in the future.

These challenges, and our responses, will resonate throughout the Puget Sound region.

Already, the region is one of America's economic juggernauts. According to the Paris-based Organization for Economic Cooperation and Development, the Seattle-Tacoma-Bellevue metropolitan area is the fourth-most productive in the world. And the ports of Seattle and Tacoma together form the eighth-largest gateway for foreign goods nationwide.

In that strength — and the strength of other metropolitan areas around the country — are the seeds of solutions.

Like the call for "three T's" in the stimulus debate — measures that are timely, targeted and temporary — policies to improve our nation's long-run economic performance and address its overhanging challenges would instead do well to focus on the "three I's" — innovation, intellect and infrastructure.

Innovation has always served to propel economic growth. Here, Puget Sound companies lead the world in the fields of aerospace, software and retailing, developing new ideas and products that trump the labor-cost advantages of offshoring.

Yet as a nation, we have fallen behind European competitors in innovative new-growth fields like alternative energy, where none of the world's 10 largest solar-cell manufacturers, and only one of the world's 10 largest wind-turbine manufacturers, is a U.S. company.

Intellect — the knowledge and skills of our people — translates into economic growth by raising worker output and incomes and creating more of the first "I," innovation.

Yet, while the United States sends the highest share of its young people to college worldwide, our rank falls to 16th when you measure who actually graduates. And though the Puget Sound region boasts one of the most-educated adult populations in the nation, the feeder system (especially Seattle's public schools) loses too many young people along the pathway to higher education.

Infrastructure supports long-term economic growth in many ways. High-quality transportation infrastructure — roads, transit, rail and ports — speeds the movement of goods and people within and across markets.

Yet, the Seattle area succeeds economically despite the real hurdles it faces on this front. Even taking into account high performers like Sea-Tac Airport and King County Metro, rising congestion highlights the lack of cogent plans for key corridors like Highway 520 and the Alaskan Way Viaduct, as well as the need for a renewed commitment to rail transit.

To its credit, the Puget Sound region, like other metropolitan areas around the country, has tried to tackle some of these issues on its own.

But, because the route to resolving our long-term challenges runs through areas like Seattle, its issues demand national attention.

For instance, shouldn't the federal government — through direct investments in scientific research and favorable tax treatment for corporate investment in research and development — help put innovative regions like Puget Sound ahead of the curve in cutting-edge "green" industries?

To upgrade our nation's intellectual capacity, shouldn't the federal government partner with states, localities and the private sector to support the diffusion of successful, entrepreneurial urban education models for districts like Seattle?

And on infrastructure, shouldn't the federal government deploy its roughly $50 billion in annual transportation expenditures in smarter ways to help relieve congestion and promote sustainability in key trade corridors like the Seattle-Tacoma area?

Once we get past the stimulus frenzy, let's have a real debate about the blueprint for bolstering America's long-term economic growth.

Building on the strengths, and addressing the challenges, of the "three I's" in regions like Seattle ought to be another strategy leaders in our nation's capital can agree upon.

Alan Berube is research director of the Metropolitan Policy Program at the Brookings Institution in Washington, D.C. David Jackson is a policy analyst with the program.

Editor’s Note: The following is a transcript of the House of Representatives’ Special Select Committee hearing on the Benghazi scandal, taking place in a parallel universe not very far away. It is satire, obviously, but perhaps only because of an almost random quirk of fate.

Representative Trey Gowdy: I would like to call this hearing to order. We are gathered today to get to the bottom of the horrific events of March 18 to 25, 2011, when over 100,000 inhabitants of Benghazi were cruelly killed in the worst act of genocide since Rwanda. Libya has since descended into a catastrophic civil war on a par with Syria, and yet Colonel Gadhafi is still in power. Worse, the situation has exacerbated extremism and threatens to spur Islamic terrorism throughout the region. The recent intervention of Russian forces in the Libyan civil war ensures that any chance the United States had of ending Gadhafi’s cruel tyranny has been missed. 

This was the greatest moral and strategic failure of U.S. foreign policy in 20 years. And yet there has been little or no accountability. Former U.N. Ambassador Susan Rice was even promoted to Secretary of State, while former National Security Council staffer Samantha Power stepped down, apparently in quiet protest at the president and Secretary Hillary Clinton’s weak and morally vacuous policy. Ms. Power's new sequel "A Problem From Hell" has now been made into the Oscar-winning movie "Hotel Benghazi." This scandal, this moral failing is now seared into the conscience of our nation.

This Special Select Committee was stood up 18 months ago and has been working diligently since that day to build on the work of multiple other congressional inquiries to get at the truth of this national shame. We know that the Obama administration had intelligence about the risk of genocide in Benghazi but it decided not to act. Indeed, the entire world knew. The questions we want answered are: What did the administration know about the approaching genocide? And when did it know it? 

We are joined by former Secretary of State Hillary Clinton. Madam Secretary, we appreciate you taking time off from the campaign trail. I understand you have a short statement. 

Secretary Hillary Clinton: Thank you, Representative Gowdy. This is my fourth time appearing before the U.S. Congress on this issue; 37 members of my staff and family have appeared, and my dog is currently fighting a subpoena. So I will keep this brief.

While we deeply regret the Benghazi genocide, we must remember that we had incomplete information about Colonel Gadhafi's intentions. We were faced with a difficult choice: Should we intervene to stop an uncertain atrocity, committing U.S. troops to an uncertain mission with no exit plan and no vital national interest? Or should we try to shape events without the use of U.S. forces, using the many other tools at our disposal? 

We decided that U.S. military intervention was not prudent. We were worried about a failed state and losing U.S. personnel on the ground. The administration instead sought to mobilize the international community to prevent any genocide and ultimately to bring Gadhafi and his henchmen to justice at the International Criminal Court. 

We continued throughout my tenure as secretary of state—and until this day—to work to bring the civil war to an end and to help the moderate Libyan opposition to overthrow the regime. 

We made some tough calls and we must acknowledge that we were not always right. Knowing what we know now, I wish that we had acted more forcefully. Indeed, I was personally in favor of a no-fly zone to protect Libyan civilians. But hindsight is twenty-twenty and the president decided to stay out. 

Representative Gowdy: Madam Secretary, with all due respect, Gadhafi's intention was quite clear. Just days before the slaughter he said, and I quote: “All of these germs, rats and scumbags, they are not Libyans.” He told them "It's over…We are coming tonight…We will find you in your closets, ” adding: “We will show no mercy.” U.S. NGOs on the ground provided detailed information of troop movements. What more evidence did you need of imminent war crime? Why did you not act? Isn’t the role of the secretary of state to persuade the president? 

If something went wrong, I would be the first to say war is unpredictable and involves risk. I am confident the Congress would have fully supported you.

Secretary Clinton: Congressman, with all due respect, Congress at the time steadfastly opposed our intervention. Had we acted and had the aftermath been messy—as we fully expected—I have no doubt that you would be calling me here to account for that, noting that our own assessments showed we had no capacity to bring stability to Libya. What if we had lost U.S. military personnel or diplomats? What if a U.S. overthrow of the Gadhafi regime merely led to more and different chaos and violence, as we saw in Iraq?

Representative Gowdy: Madam Secretary, the greater shame is clearly inaction in the face of a moral imperative. I can assure you, and I feel confident I speak for all of my colleagues, that had you acted, we would have had your back, come what may. If something went wrong, I would be the first to say war is unpredictable and involves risk. I am confident the Congress would have fully supported you. 

Secretary Clinton: Thank you Congressman, but you will excuse me if I still have some doubts on that score. I guess we’ll never know.