XPOSTFACTOID-test

2011-07-07T06:06:00.000-07:00

Quote test no enters

2010-01-26T18:46:00.000-08:00

This post is written with no line breaks between the text blocks and *then* the quote attribute is added providing line breaks.

And then she was like whatever and I was like well that's like because you were so like and she was all yeah whatever that's so like and I was all don't go there don't be so and he was like like I want to and she was all...

Lorem Ipsum is simply dummy text of the printing and typesetting industry. Lorem Ipsum has been the industry's standard dummy text ever since the 1500s, when an unknown printer took a galley of type and scrambled it to make a type specimen book. It has survived not only five centuries, but also the leap into electronic typesetting, remaining essentially unchanged. It was popularised in the 1960s with the release of Letraset sheets containing Lorem Ipsum passages, and more recently with desktop publishing software like Aldus PageMaker including versions of Lorem Ipsum.

It is a long established fact that a reader will be distracted by the readable content of a page when looking at its layout. The point of using Lorem Ipsum is that it has a more-or-less normal distribution of letters, as opposed to using 'Content here, content here', making it look like readable English. Many desktop publishing packages and web page editors now use Lorem Ipsum as their default model text, and a search for 'lorem ipsum' will uncover many web sites still in their infancy. Various versions have evolved over the years, sometimes by accident, sometimes on purpose (injected humour and the like).

Arr, matey, walk the plank and meet Davey Jones.

The quick brown fox jumped over the lazy dog.

Quote test, with enters

2010-01-26T18:44:00.000-08:00

This post is written with line breaks between the text blocks and *then* the quote attribute is added
Testing some quotes, quoting some texts, questing some totes....

And then she was like whatever and I was like well that's like because you were so like and she was all yeah whatever that's so like and I was all don't go there don't be so and he was like like I want to and she was all...

Lorem Ipsum is simply dummy text of the printing and typesetting industry. Lorem Ipsum has been the industry's standard dummy text ever since the 1500s, when an unknown printer took a galley of type and scrambled it to make a type specimen book. It has survived not only five centuries, but also the leap into electronic typesetting, remaining essentially unchanged. It was popularised in the 1960s with the release of Letraset sheets containing Lorem Ipsum passages, and more recently with desktop publishing software like Aldus PageMaker including versions of Lorem Ipsum.

Arr, matey, walk the plank and meet Davey Jones.

The quick brown fox jumped over the lazy dog.

Good night, Dish

2009-12-20T14:55:00.000-08:00

Time to sign off. Blogging here at the Dish this week has been a joy to me, and I hope of some use or pleasure to readers. Many thanks to Andrew, who I hope returns recharged, and to Patrick and Chris for working my posts into the flow while keeping things lively all week.

Please stop in at my blog, xpostfactoid, and let me know your thoughts.

Buffalo Garden Walk '08

2009-12-14T08:10:00.000-08:00

Churchill's memo to Obama

2009-11-27T06:54:00.000-08:00

A warning to Obama as he prepares to unveil his new Afghan strategy:

Never, never, never believe any war will be smooth and easy, or that anyone who embarks on the strange voyage can measure the tides and hurricanes he will encounter. The statesman who yields to war fever must realise that once the signal is given, he is no longer the master of policy but the slave of unforeseeable and uncontrollable events. Antiquated War Offices, weak, incompetent, or arrogant Commanders, untrustworthy allies, hostile neutrals, malignant Fortune, ugly surprises, awful miscalculations - all take their seats at the Council Board on the morrow of a declaration of war. Always remember, however sure you are that you could easily win, that there would not be a war if the other man did not think he also had a chance.
Winston Churchill, My Early Life: A Roving Commission (1930), Chapter 18 (With Buller To The Cape), p. 246 (cited in Wikiquote).

Obama's long deliberation might make such a warning seem superfluous (and certainly no one engaged the Afghanisan effort seems prone to war fever -- except the Taliban). The danger for his team seems to lie not in overlooking these truths but in hyper-awareness of them. As Rory Stewart has suggested, the very scope and perfectionism of McChrystal's plans -- and perhaps of Obama's subsequent plans on top of plans -- suggests a will to overpower these deeply rooted forces and limitations in human social organization. Of course, all wartime leaders must will to overcome them -- relative to the enemy, in any case. The danger perhaps lies in seeking to accomplish the aims of war on terms acceptable to a deeply ambivalent populace, exhausted military and depleted treasury.

A Wrinkle in (Presidential) Time

2009-11-25T11:29:00.000-08:00

A bit of free association below, keying off George Packer's musing about the disillusionment he's hearing on his book tour from young Obama supporters (h/t Andrew Sullivan). Packer:

The most disappointed people I meet are under thirty, the generation that made the Obama campaign a movement in its early primary months. They spent their entire adult lives under the worst President of our lifetime, they loved Obama because he was new and inspiring, and they felt that replacing the former with the latter would be a national deliverance. They weren’t wrong about that, but the ebbing of grassroots energy once the Obama campaign turned to governing suggests that some of his most enthusiastic backers saw the election as an end in itself. The Obama movement was unlike other social movements because it began and ended with a person, not an issue. And it was unlike ordinary political coalitions because it didn’t have the organizational muscle of voting blocs. The difficulty in sustaining its intensity through the inevitable ups and downs of governing shows the vulnerability in this model of twenty-first-century, Internet-based politics.

The triggered memory is of the disillusioned twelve-year heroine of the children's fantasy A Wrinkle in Time after she catches up in a far-off galaxy with her adored, longed-for, long absent father:

She had found her father and he had not made everything all right. Everything kept getting worse and worse. If the long search for her father was ended, and he wasn't able to overcome all their difficulties, there was nothing to guarantee that it would all come out right in the end. There was nothing left to hope for. She was frozen, and Charles Wallace was being devoured by IT, and her omnipotent father was doing nothing. (Ch. 10: Absolute Zero).

Those of us who are not disillusioned -- who are thankful that the Obama Administration has ended the torture regime, and restored U.S. standing in the world, and averted a second depression, and perhaps rescued the domestic auto industry, and is on the brink of shepherding through a remarkably balanced health care reform bill -- we are prone to an equally childlike error: investing Obama with the properties of what the Freudian psychoanalyst Lacan called "the one presumed to know." When presented with an apparent Obama error of policy or presentation, the reflex is to assume that he's "playing a long game," thinking five moves ahead, not focused on the daily news cycle, etc. etc. -- rather than that he or his surrogates just miscalculated, or suffered a failure of nerve, or failed to pay attention, or otherwise erred.

Thus Obama did not give up too much too soon on the stimulus, which was as large as could be passed; he has not been too passive as the health care reform bills have undulated through Congress; he was wise to let the Republicans expose their scorched earth intransigence by extending his hand early; he did not get rolled by the Chinese on his public exposure or human rights advocacy; he could not have expressed firmer support for the Green Revolution in Iran without undermining it; his long pause on Afghanistan is something to celebrate; his mend-it-don't-end-it approach to megabanking is the most efficient do-no-harm approach. I do actually believe that some of these assertions are true; others, not; still others, it's hard to say yet. On health care, in particular, I think that his light touch is shaping a better bill than a more ostentatious leadership posture would have. But I also think that there's something of a pattern of Obama not pushing hard enough, advocating forcefully enough, attacking frontally enough or engaging publicly enough. Still, on this Thanksgiving Day, I am thankful in the extreme that the U.S. has a President of such enthralling intelligence, fundamental decency and formidable shrewdness.

On the question of how much disillusionment is warranted, the full posts of Packer and Sullivan (links at top) are well worth reading.

The party of federal debt and the path to sustainability

2009-11-25T06:09:00.000-08:00

Lest anyone forget that Republicans have for a generation been the party of federal debt, a timely reminder from Martin Wolf:

In the case of the US, 1.8 percentage points of a 6.5 percentage point deterioration will be due to such measures. Most of the change is structural: the levels of GDP and fiscal revenue will not return to the previous path....the rise in the debt ratio is comparable to that in big wars – smaller than the second world war, but larger than in the civil war and the first world war. But this is not the first time the US has had a huge increase in its debt ratio in peacetime. The first occasion was under the Republicans between 1981 and 1992. That was when they discovered supply-side economics.

Supply-side fervor went hand-in-glove with deregulatory fervor - which, to be fair, also infected Clintonian Democrats. Hence the need for a massive course correction by the party of relative fiscal responsibility -- the Democrats.

Wolf goes on to assert that the debt ratio is large but manageable in the short-to-medium term; that it's too early for fiscal tightening now, and that doing so could trigger a double-dip recession; but that the debt will remain manageable only if the country soothes creditors by demonstrating "credible fiscal institutions," e.g., by putting "prospective entitlement spending...on a sustainable path" and "putting in place a credible long-term tightening that responds to recovery automatically."

While Wolf, who's writing simultaneously about the U.S. and U.K., cites public pensions as a locus for entitlement reform, it's been amply demonstrated that the crucial long-term fiscal challenge for the U.S. is to curb the growth of health care spending.

So bring on the health care reform bill, with strong cost controls. And as David Leonhardt reminds us today: if any self-styled 'budget hawks' in Congress are truly queasy about that bill on fiscal grounds, let them put up -- by moving to strengthen its considerable but shifting cost controls -- or shut up.

Movin' Meat mulls Senate bill's cost controls

2009-11-24T18:13:00.000-08:00

Ron Brownstein's roundup of expert reaction to the cost-cutting measures in the Reid health care reform bill includes this "venture capital approach" from former CBO director Robert Reischauer:

"CBO is there to score savings for which we have a high degree of confidence that they will materialize," says Reischauer, now president of the Urban Institute. "There are many promising approaches [in these reform ideas] but you...can't deposit them in the bank." In the long run, Reischauer says, it's likely "that maybe half of them, or a third of them, will prove to be successful. But that would be very important."

Seconding that reaction is a more concrete way is the ER doctor who writes the Movin' Meat blog, which offers a running practitioner's view of the health care reform process. Dr. Meat annotates Brownstein's summary of the key cost-cutting provisions; he finds some underwhelming, some of uncertain effect -- and some likely to have a powerful impact. A short sample:

"The Finance Bill proposed automatic reimbursement reductions for doctors who order up the most care for Medicare recipients with similar medical and demographic characteristics. That was meant to respond to the research showing big disparities in spending on medical services for similarly-situated patients in different communities. ... the final bill takes a less direct route toward a similar end. It requires Medicare to begin studying the utilization patterns of doctors participating in the program. And then it establishes a "values based payment modifier" that would, in a budget-neutral manner, increase reimbursements for physicians found to deliver high-quality care at lower cost, and reduce them for physicians at the other end of that spectrum."
Wow. I was unaware of this. Would it be unfair to call this the "Gawande provision?" That New Yorker article was highly influential. As someone who works in a "high quality low cost" system, I like the idea of being paid for being more efficient -- we have been penalized for many years. I like that it is budget neutral. I worry that since it does not decouple payment from volume, that the low-efficiency area practices may respond by simply further increasing volume to make up for lost revenue. When it's a revenue neutral game, there will always be someone at the bottom -- will this polarize practice patterns or reduce the disparities? I don't know.

Another Republican cost-containment priority missing from the bill is meaningful medical malpractice reform. (The bill only encourages states to think about it.)"

Yes, this is a pity. However, I blame this entirely on the Republicans. We know that the Democrats have been four-square against tort reform for time out of mind. There is no way they were going to put it in their bill on their own. If Chuck Grassley had offered five solid GOP votes for the overall package in return for real malpractice reform, I am sure that Obama would have jumped at it. Who wouldn't? There would have been no last-minute drama over whether the bill was going to pass, the compromises would have been made in committee, and both the Democrats and GOP would have been able to claim to their constituencies that they had accomplished long-standing objectives. Instead, the GOP chose immutable opposition as their strategy and as a result the bill reflects not one of their priorities. Reap the whirlwind, boys.

The conclusion bespeaks an interested party willing and able to look at issues in the round:

Overall, it's promising -- as a start. I don't think this will be the end, not by a long shot. A large number of critics claim that the health reform bills do "nothing" to control costs. This is not nothing -- not by a long shot. Whether it will work at all, or whether it will do enough are open questions. I also find it interesting that the providers who have been most concerned about the escalation of health care costs (I'm looking at you, Kevin) have not weighed in on this element of reform. As a provider, I have really mixed feelings about the potential for cost containment to (further) erode physician autonomy and to (further) reduce physician income. However, no sane person can look at the rate of medical inflation and not see the burning need for cost containment. I just worry that too much of it will fall on our shoulders, since reining in costs any other way is tricky and politically unpopular.

There, Mr President, I've done my homework. Do I get extra credit?

Extra credit is when the President circulates your analysis - as he reportedly did Brownstein's. Rahm, move this meaty response.

David Brooks gins up another faux consensus

2009-11-24T08:08:00.000-08:00

"It’s easy to get lost in the weeds," David Brooks warns, "when talking about health care reform." So Brooks, that genial guide, kindly leads readers off a cliff.

Declining to explain in any detail why he thinks the robust cost-control measures in the Senate health care bill would fail if enacted, Brooks relies instead on his two old stand-bys: mushy generalizations about values and recourse to faux consensus.

What a society gains in security through social welfare programs, Brooks declares without any evidence, it usually loses in vitality. There's a caveat:

Occasionally, our ancestors found themselves in a sweet spot. They could pass legislation that brought security but without a cost to vitality. But adults know that this situation is rare

Interesting to cast successful social welfare programs as the domain of our "ancestors." That projects such doings into a mythical realm, akin the age of prophecy that rabbis deemed to have ended after the post-exilic prophets. Needless to say, then, health care reform won't reach that state of grace. By enacting it, we will sap our vitality!

Perhaps in his next column Brooks can explain how dozens of wealthy countries that provide health care to all their citizens at half to two-thirds the per capita spending of the U.S. have sacrificed their "vitality." Or how subjecting tens of millions of Americans to subpar care and constant risk of financial ruin magically confers "vitality" on the U.S. -- rather than sapping it by chaining people to their current jobs, assuming they can hold them and that their employers do not scuttle or eviscerate their health plans.

According to Brooks, the great vitality drain will presumably be triggered when an enacted reform bill accelerates rather than controlling health care spending and thus redistributes wealth to the most vulnerable. To make this argument he relies on the device he used three weeks ago to prove that Obama lacked the grit to win in Afghanistan: conjuring consensus out of thin air. Here's how it works this time:

The authors of these bills have tried to foster efficiencies. The Senate bill would initiate several interesting experiments designed to make the system more effective — giving doctors incentives to collaborate, rewarding hospitals that provide quality care at lower cost. It’s possible that some of these experiments will bloom into potent systemic reforms.
But the general view among independent health care economists is that these changes will not fundamentally bend the cost curve. The system after reform will look as it does today, only bigger and more expensive.
As Jeffrey S. Flier, dean of the Harvard Medical School, wrote in The Wall Street Journal last week, “In discussions with dozens of health-care leaders and economists, I find near unanimity of opinion that, whatever its shape, the final legislation that will emerge from Congress will markedly accelerate national health-care spending rather than restrain it.”

Now, Dr. Flier is indeed a formidable authority. Doubtless he has spoken with many colleagues and experts as he claims. But his assertion of "near unanimity" is just that -- an assertion. Brooks leverages it -- without relaying Flier's substantive argument in any detail -- into "the general view among independent health care economists."

No such "general view" exists. I don't know of any WSJ-style survey of health care economists and experts. But there's good reason to believe that consensus is closer to the opposite view, as Ronald Brownstein suggests in a widely-cited article about expert response to Reid's bill. Here's a centerpiece of the feedback Brownstein reports "from the center to the left":

In their November 17 letter to Obama, the group of economists led by Dr. Alan Garber of Stanford University, identified four pillars of fiscally-responsible health care reform. They maintained that the bill needed to include a tax on high-end "Cadillac" insurance plans; to pursue "aggressive" tests of payment reforms that will "provide incentives for physicians and hospitals to focus on quality" and provide "care that is better coordinated"; and establish an independent Medicare commission that can continuously develop and implement "new efforts to improve quality and contain costs." Finally, they said the Congressional Budget Office "must project the bill to be at least deficit neutral over the 10-year budget window and deficit reducing thereafter."

As OMB Director Peter Orszag noted in an interview, the Reid bill met all those tests.

The Garber letter is signed by 23 leading economists, including two Nobel laureates, Kenneth Arrow of Stanford and Daniel McFadden of Berkeley. A third Nobel Laureate, William F. Sharpe, asked for his name to be added to the list of signers, according to the Harvard Crimson.

Brooks does not bother with the substance of Dr. Flier's argument. That argument boils down to three points: 1) the pending health reform bills are structurally similar to the Massachusetts quasi-universal coverage bill passed in 2006; 2) the Massachusetts bill has not slowed health care inflation, and 3) Massachusetts is just now turning its attention to serious means of controlling costs. Here's where the argument gets curious:

A "Special Commission on the Health Care Payment System" recently declared that the Massachusetts health-care payment system must be changed over the next five years, most likely to one involving "capitated" payments instead of the traditional fee-for-service system. Capitation means that newly created organizations of physicians and other health-care providers will be given limited dollars per patient for all of their care, allowing for shared savings if spending is below the targets. Unfortunately, the details of this massive change—necessitated by skyrocketing costs and a desire to improve quality—are completely unspecified by the commission, although a new Massachusetts state bureaucracy clearly will be required.

Yet it's entirely unclear how such unspecified changes would impact physician practices and compensation, hospital organizations and their capacity to invest, and the ability of patients to receive the kind and quality of care they desire. Similar challenges would eventually confront the entire country on a more explosive scale if the current legislation becomes law.

Selling an uncertain and potentially unwelcome outcome such as this to the public would be a challenging task. It is easier to assert, confidently but disingenuously, that decreased costs and enhanced quality would result from the current legislation.

So: Massachusetts has not yet worked out the details of serious structural reform. Those details -- and on this point there is something approaching a consensus, which appears to include Dr. Flier -- must be worked out incrementally, by trial and error. That is precisely what the Senate bill -- in contrast to the Massachusetts bill -- aims to do from the outset. Brownstein again, on the bill's measures to seed structural reform:

The other set of Baucus proposals were intended to promote more coordination among providers. These have survived almost verbatim into the final bill. The bill encourages groups of providers to establish doctor-led "accountable care organizations" to more comprehensively manage patients' care by allowing them to share in any savings for Medicare they produce. It also establishes a voluntary national pilot of "bundled" payments that would encourage hospitals, doctors and other providers to work more closely together. Another pilot program would test coordinated home-based care for chronically ill seniors.

Dr. Flier plainly does not think much of these measures. He asserts, without any detailed enumeration or assessment of them:

Likewise, nearly all agree that the legislation would do little or nothing to improve quality or change health-care's dysfunctional delivery system. The system we have now promotes fragmented care and makes it more difficult than it should be to assess outcomes and patient satisfaction.

Nor does Dr. Flier assess the likely effects of an empowered Medicare commission or of the excise tax on expensive plans. He may have excellent reasons, based on practice experience and discussion with colleagues, to believe that the package of cost control measures won't work. But he's content to merely assert them.

Brownstein relays what appears to me a more balanced, if hardly rapturous assessment:

Former CBO director Robert Reischauer, who signed the November 17 letter, says that's not surprising. "CBO is there to score savings for which we have a high degree of confidence that they will materialize," says Reischauer, now president of the Urban Institute. "There are many promising approaches [in these reform ideas] but you...can't deposit them in the bank." In the long run, Reischauer says, it's likely "that maybe half of them, or a third of them, will prove to be successful. But that would be very important."

And from Mark McClellan, Bush's director of the Center for Medicare and Medicaid Services:

McClellan, the former Bush official and current director of the Engleberg Center for Health Care Reform at the Brookings Institution, was one of the economists who signed the November letter. McClellan has some very practical ideas for improving the Reid bill (more on those below), but generally he echoes Orszag's assessment of it. "It has got all four of those elements in it," McClellan said in an interview. "They kept a lot of the key elements of the Finance bill that I like. It would be good if more could be done, but this is the right direction to go."

Brownstein's article was published three days before Brooks' and has circulated widely. But Brooks does not engage it -- or any other of the formidable health care experts who are voicing support for the Reid bill's cost control measures. Instead, he reverts to the tiredest and most circular of Republican talking points against those measures:

Moreover, the current estimates almost certainly understate the share of the nation’s wealth that will have to be shifted. In these bills, the present Congress pledges that future Congresses will impose painful measures to cut Medicare payments and impose efficiencies. Future Congresses rarely live up to these pledges. Somebody screams “Rationing!” and there is a bipartisan rush to kill even the most tepid cost-saving measure. After all, if the current Congress, with pride of authorship, couldn’t reduce costs, why should we expect that future Congresses will?

Ezra Klein has dealt nicely (and repeatedly) with the embedded logic of such critiques:

More broadly, I'm confused by the budget hawks who that take the line: "This bill needs to cut the deficit, and I don't believe Democrats will cut the deficit, but since the actual provisions of the bill unambiguously cut the deficit, then I guess Congress won't stick to it."

People who want to cut the deficit should support this bill, and support its implementation. The alternative is no bill that cuts the deficit, and thus no hope of cutting the deficit.

Klein has internalized the argument of Harvard's Jonathan Gruber - another signatory of the Garber letter -- who put it this way when he spoke to Klein:

We know we will be closer to bending the curve with this bill than without it. But we can't promise this bill alone will bend the curve. This bill moves us towards that. First is the Cadillac tax. Then comes more research on comparative effectiveness. We need to be able to stop paying for things that don't work. This bill doesn't do that, but it sets us up to have the information to do that. Then there's MedPAC on steroids. You need someone with the political ability to set rates to controls costs. Finally, this bill has pilot programs for a lot of things that we think will control costs, but that haven't been proven. Things like accountable care organizations, bundling and all the rest. We're at the stage where we know in theory what to do. But we don't quite know how to set it up, so we're collecting that evidence.

I think this is as much as you can do politically. It's as much as you can do without sinking the whole bill, which is what happened to every other health-care reform.

Finally, one more advocate of this kind of incremental approach to change is worth listening to:

At this point, I am confident that both the House and the Senate bills will contain what we've been calling MedPAC on steroids, the idea that you continually present new ideas to change incentives, change the delivery system, understanding that because this is such a complex system we're not always going to get it exactly right the first time, and that there have to be a series of modifications over the course of a series of years, and we have to take that out of politics and make sure that an independent board of medical experts and health economists are providing packages that are continually improving the system. So I think there's general consensus that that is one of two very powerful levers to bend the cost curve.

That's a certain Barack Hussein Obama, speaking to Fred Hiatt on July 26. A man whose M.O. is always to move the battleship by a few degrees.

Water on a Stone: Fallows relays an insider's view of Obama's Chinese conversations

2009-11-22T14:36:00.000-08:00

James Fallows has been pushing back in multiple posts against the shallow horse-race coverage of Obama's China trip. The centerpiece is his relay of an anonymous insider's view of what Obama's meetings with Chinese leadership did and did not accomplish, offered here and here. This account is nuanced and neutral enough - claiming no great triumphs, relaying both incremental moves toward cooperation and roadblocks - to come across as highly credible, nothwithstanding that it comes from an Administration member. Here's the summation:

"Discussions with the Chinese just don't offer dramatic breakthrough
moments. It's water on a stone. They don't reveal their Eurekas to you. While you're there you get fairly predictable responses. Next time you go back and get a little different treatment."Judgments will be borne out over time. Will they cooperate or not on Iran? Will they be spoilers or not on climate change? On North Korea? Rebalancing their economy? None of those is a one-day story. The only fair way of evaluating results will be over time.

And a sampling of that "water on a stone" progress, on global warming:

"We closed some of the gap but not all of the gap. The Chinese do not wish, three weeks out of Copenhagen, to be seen working hand in glove with the US to impose a "G2" solution to the G77. They have their own reservations about how far things should go. But they also don't want to be seen as the stumbling block or odd man out."We kept making the argument, We're the #1 and 2 emitters, so we have a special responsibility, a special role. We got some movement. They are taking substantial mitigating steps, which they didn't enumerate but we know
what they are. As best we can tell, they are prepared to submit those as their "target" in Copenhagen, and of course we want them to be "commitments" rather than targets. There is still a stumbling block on the issue of accountability, which is always a hard one with the Chinese. We'd like to have an independent peer review of whether doing what you said you would do. There are lots of different ways to do that... But we haven't closed that part of the gap yet.

Read the whole thing(s), parts 1-4 of Fallows' critique of media coverage of the trip.

Update: Part 5 is up, and includes a validation, from a 20-year resident of China, of my own sense of the power of Obama's core message to Chinese youth in the town hall -- his embrace of criticism of himself as a spur that "makes me a better leader because it forces me to hear opinions that I don't want to hear."

A 'beautiful bill' goes to the operating table

2009-11-22T06:42:00.000-08:00

Before a month of Senate debates whacks all the loveliest limbs off the health care reform statue, the bill's intellectual fathers are gazing up at the pedestal with something like rapture.

Ronald Brownstein rounds up accolades for the bill's cost-control measures from "analysts from the center to the left." (And it should be noted that "the center to the left" in the U.S. healthcare debate is center-to-right in just about any other first-word democracy. Per Paul Starr, the HRC bills moving through House and Senate are a compendium of Republican ideas proposed from Congressman Nixon in the late 1940s through President Nixon in 1974 to George H.W. Bush, Bob Dole and John Chafee in the early 90s.) Brownstein:

In their November 17 letter to Obama, the group of economists led by Dr. Alan Garber of Stanford University, identified four pillars of fiscally-responsible health care reform. They maintained that the bill needed to include a tax on high-end "Cadillac" insurance plans; to pursue aggressive" tests of payment reforms that will "provide incentives for physicians and hospitals to focus on quality" and provide "care that is better coordinated"; and establish an independent Medicare commission that can continuously develop and implement "new efforts to improve quality and contain costs." Finally, they said the Congressional Budget Office "must project the bill to be at least deficit neutral over the 10-year budget window and deficit reducing thereafter."

As OMB Director Peter Orszag noted in an interview, the Reid bill met all those tests.

Positively effusive is Jonathan Gruber of MIT:

I'm sort of a known skeptic on this stuff," Gruber told me. "My summary is it's really hard to figure out how to bend the cost curve, but I can't think of a thing to try that they didn't try. They really make the best effort anyone has ever made. Everything is in here....I can't think of anything I'd do that they are not doing in the bill. You couldn't have done better than they are doing."

I find myself viewing this legislative process with what the medievals would call a "double chere" - a dual perspective. On the one hand there's the unlovely legislative process, nicely reported and themed today by Dana Milbank noting the latest concessions extracted by Blue Dog and other Democrats. Milbank spotlights the leveraging of withheld support:

After Landrieu threw in her support (she asserted that the extra Medicaid funds were "not the reason" for her vote), the lone holdout in the 60-member Democratic caucus was Sen. Blanche Lincoln of Arkansas. Like other Democratic moderates who knew a single vote could kill the bill, she took a streetcar named Opportunism, transferred to one called Wavering and made off with concessions of her own. Indeed, the all-Saturday debate, which ended with an 8 p.m. vote, occurred only because Democratic leaders had yielded to her request for more time.

Note, though, that - none of the concessions chronicled by Milbank substantively weakens the bill, and one - the Wyden amendment modestly expanding access to the exchanges - improves it. Which brings me to the second "chere": so far, the legislation is remarkably balanced, prudent, well designed to square the circle of expanding access without increasing the deficit by wringing waste out of the system and taxing in ways that won't affect productivity. If the Baucus bill's core cost-control measures substantially survive, and the final bill is leavened with more expanded access than the Baucus bill provided for, the result will look awfully like what an Obama supporter might have hoped his subtly shaping hand would have wrought.

That, of course, is a big "if." The prospect of a bill essentially like the one now brought to the Senate floor actually becoming law -- and then not being hacked to pieces by a resurgent Republican party by say 2014 -- has the giddy feel of fantasy. Certainly some pounds of flesh will be extracted -- a Stupak Amendment? a gutted public option? at least one cost-cutting pillar (excise tax?) knocked out? So breath remains bated. These are times that try one's faith that the Federal government, in the wake of a major electoral course correction, can still create legislation that improves Americans' quality of life and puts the economy on a more sustainable footing. Faith, that is, that the U.S. is still governable.

A Wolf whistle on bankers' pay

2009-11-20T05:57:00.000-08:00

Almost two years ago, FT economics columnist Martin Wolf surprised himself (rhetorically, anyway) by seconding a proposal by Raghuram Rajan, former chief economist of the International Monetary Fund, that regulators force banks to tie bonus pay to long-term performance:

Yet individual institutions cannot change their systems of remuneration on their own, without losing talented staff to the competition. So regulators may have to step in. The idea of such official intervention is horrible, but the alternative of endlessly repeated crises is even worse.

Today, Wolf further surprises himself by calling for a windfall tax on bankers' bonuses. Here's how his case begins:

Windfall taxes are a ghastly idea. They are a sop to prejudice, a burden on risk-taking and a form of arbitrary confiscation.

So Wolf once again casts his stance as a Nixon-to-China moment. But the logic seems incontrovertible:

“Windfall” support should be matched by windfall taxes.

And in a bit more detail:

Fourth, ordinary people can accept that risk takers receive huge rewards. But such rewards for those who have been rescued by the state and bear substantial responsibility for the crisis are surely intolerable. What makes them yet more so is that the crisis has devastated the prospects of tens, if not hundreds, of millions of innocents all over the globe. The public finances will be devastated for decades: taxes will be higher and public spending lower. Meanwhile, bankers are about to reap huge rewards. This damages the legitimacy of the market economy.
Fifth, it is hard to argue in favour of exceptional interventions to bail out the financial sector at times of crisis, and also against exceptional interventions to recoup costs when the crisis is past. “Windfall” support should be matched by windfall taxes.

If a nonideological free marketer like Wolf can make this case seem watertight, there ought to be ample cover for a large Democratic majority badly in need of landing a populist blow. But then, Wolf presumably doesn't take campaign contributions.

Oxfam's survey of Afghans: their wishes are no mystery

2009-11-19T16:59:00.000-08:00

An Oxfam poll of 704 randomly selected Afghans reveals untold suffering-- 1 in 5 say they've been tortured, three quarters have been forced to leave their homes at some point in the endless civil war, 43% have had property destroyed. The survey also has what would seem to be some moderately encouraging findings regarding the counterinsurgency: 70% see unemployment and poverty as a key driver of civil war; 48% blame the government's weakness and corruption; 36% point to the Taliban; 25% to interference by neighboring countries; just 18% to the presence of international forces; another 18% to d al Qaeda-- and another 17% to the lack of support from the international community. After 30 years of civil war, only 3% named the current conflict as the most harmful period (though the report cautions that areas where the current fighting is worst are underrepresented).

The Oxfam recommendations, channeled through selected comments of the surveyed Afghans, are not surprisingly a mirror of McChrystal's stated goals and strategies: provide not only more aid but more effective aid; root out Afghan government corruption; stop killing civilians via airstrikes; desist from invasive and violence house searches; hold coalition forces that kill or abuse the population accountable for their actions; respect the local culture.

Oxfam adds "recommendations" for the Taliban, delivered deadpan, without irony -- which in a sense produces its own irony. Most western observers are hyper-conscious by now that killing civilians undermines support; but both the survey numbers and the quoted comments make it clear that the Taliban's wanton killings make it less popular than the coalition forces or the government. Likewise, what seems a bold speculative move to some western strategists comes across as a weary necessity from Afghan civilians:

Our message to the Taliban is that they should take part in the government - Male, Herat

The Taliban should not fight; they should express their demands through dialogue - Male, Kabul

Our message to the Taliban is that if they are really Muslim, then why are they fighting against the government since the government is also an Islamic government? - Male, Baikh

One gets the impression that the Afghans have no illusions about their government, and also no illusions about the Taliban. They are more war weary than we can fathom -- and like Richard Holbrooke, they will know success -- -- any modicum of peace, justice and development -- when they see it . Or rather, they would know it if they were ever to see it. They were apparently not surveyed as to hopes.

Mea Culpa re Obama in China

2009-11-17T16:41:00.000-08:00

In my prior post about Obama's speech and q-and-a with students in Shanghai, my usual intoxication with the intricate structure of Obama's speechmaking blinded me to the broader context in which he allowed the speech to take place -- with no broadcast to the Chinese people as a whole. To a degree Obama seems to have hit the mute button on human rights in China, failing either to raise the issues or gain the exposure that Bush and Clinton did before him. The FT's Edward Luce and Geoff Dyer portray a two-track muting:

In contrast to the last two US presidential visits to China - George W. Bush in 2002 and Bill Clinton in 1998, both of whose words were broadcast live and widely to the Chinese public - Mr Obama's 60-minute question-and-answer session in Shanghai was heavily restricted.
Only the citizens of Shanghai were able to watch it live on local broadcasts. Elsewhere, Chinese citizens were theoretically able to view the event on the White House website , although many reported huge difficulties in accessing either images or sound via the site.
The irony was hard to miss. In spite of weeks of pressure from US officials to open the event to the public the Chinese held their ground. Yet in contrast to his two most recent predecessors, who criticised China for detaining dissidents and suppressing freedom of religion in Tibet, Mr Obama studiously avoided giving his hosts any explicit cause for offence.
Furthermore, Mr Obama's dextrous attempts to avoid provoking the Chinese were heavily censored. Phoenix television, a Hong Kong-based channel with broadcasts on the mainland, carried the first few minutes of Mr Obama's speech at the start of the meeting but cut to another item before he made a relatively generic pitch for universal values.

In concert with the (apparently Hillary-driven) flip-flop on stopping Israeli settlement growth, Obama is starting to look like he can be pushed around. I do not believe that that will prove to be the case over time. But Gideon Rachman was right. On the international as well as the national stage, Obama needs to land a punch -- as I expect he will on his own sweet time, with the ground thoroughly laid. Though after the wild flailing of the Bush years, he seems to regard reassurance as the better part of strength. And again, per my prior post, there is a shining, supreme confidence, packing a wallop of its own, in a message such as "we do not seek to contain China's rise."

UPDATE 11/22: James Fallows has choreographed multiple voices to push back powerfully against the dominant media narrative that portrayed Obama's China trip as a failure. The centerpiece, a summary of the state of negotiations on mulitple interviews provided anonymously by a U.S. participant, makes it clear that U.S.-China negotiations are always "water on a stone," that it's too early to judge the effects of this first round, but that the engagement was substantive and constructive. Other informed reports relayed by Fallows indicate that Obama did reach a broad Chinese audience and may have stirred them deeply (as I assumed he would, reading the transcript) in the town hall. I do believe, and never really doubted, that this is true on substance. But as the last voice Fallows has cited in this series so far points out, the Obama team has done a poor job managing perceptions of the trip here in the U.S.

Obama pitches "The End of History" in Shanghai

2009-11-16T06:48:00.000-08:00

By now the scene that played out in Shanghai yesterday is familiar: Obama first addressing and then fielding questions from young students in a far-off quarter of the globe.

In these forums, Obama makes a case for values every American president promotes in speeches: freedom of speech, freedom of information, equal rights for all citizens, accountable government. But for those of us who admire the basic architecture of Obama's thinking and rhetoric, these youth forums are balm after the Bush years. Obama doesn't simply promote these values; he exemplifies them, in the complexity and clarity and nuance of the way he presents them. He is an embodiment of American values, not because of the ethnic heritage he always cites, but because of the way his mind works.

In the question period in Shanghai, he was plainly aiming not so much to argue for freedom -- some have hit him for not engaging directly with Chinese human rights absues -- as to waken in his young audience a thirst for it. Here's part of his response to a "how can a student be successful like you" question:

You know, the people who I meet now that I find most inspiring who are successful I think are people who are not only willing to work very hard but are constantly trying to improve themselves and to think in new ways, and not just accept the conventional wisdom...

But I think that whatever field you go into, if you're constantly trying to improve and never satisfied with not having done your best, and constantly asking new questions -- "Are there things that I could be doing differently? Are there new approaches to problems that nobody has thought of before, whether it's in science or technology or in the arts? -- those are usually the people who I think are able to rise about the rest.

That is plainly not a mainstream message in Chinese culture. It's not an explicitly political message. But it connects back to a prior answer in which Obama referred to his own experience to make the case for open criticism of government (when asked whether Chinese should be able to use Twitter freely):

I think that the more freely information flows, the stronger the society becomes, because then citizens of countries around the world can hold their own governments accountable. They can begin to think for themselves. That generates new ideas. It encourages creativity.
And so I've always been a strong supporter of open Internet use. I'm a big supporter of non-censorship. This is part of the tradition of the United States that I discussed before, and I recognize that different countries have different traditions. I can tell you that in the United States, the fact that we have free Internet -- or unrestricted Internet access is a source of strength, and I think should be encouraged.

Now, I should tell you, I should be honest, as President of the United States, there are times where I wish information didn't flow so freely because then I wouldn't have to listen to people criticizing me all the time. I think people naturally are -- when they're in positions of power sometimes thinks, oh, how could that person say that about me, or that's irresponsible, or -- but the truth is that because in the United States information is free, and I have a lot of critics in the United States who can say all kinds of things about me, I actually think that that makes our democracy stronger and it makes me a better leader because it forces me to hear opinions that I don't want to hear. It forces me to examine what I'm doing on a day-to-day basis to see, am I really doing the very best that I could be doing for the people of the United States.

And I think the Internet has become an even more powerful tool for that kind of citizen participation. In fact, one of the reasons that I won the presidency was because we were able to mobilize young people like yourself to get involved through the Internet. Initially, nobody thought we could win because we didn't have necessarily the most wealthy supporters; we didn't have the most powerful political brokers. But through the Internet, people became excited about our campaign and they started to organize and meet and set up campaign activities and events and rallies. And it really ended up creating the kind of bottom-up movement that allowed us to do very well.

Now, that's not just true in -- for government and politics. It's also true for business. You think about a company like Google that only 20 years ago was -- less than 20 years ago was the idea of a couple of people not much older than you. It was a science project. And suddenly because of the Internet, they were able to create an industry that has revolutionized commerce all around the world. So if it had not been for the freedom and the openness that the Internet allows, Google wouldn't exist.

Th answer is multilayered. Obama asserts that he's a better President and better thinker for being severely criticized. That the forces that brought him to power are inseparable from the forces that allow him to be excoriated. And that the forces that bring such a leader to the fore also foster companies like Google. As he does more explicitly in his opening speech, Obama connects economic successs to freedom of thought.

Philip Stephens credited Obama early this year for "realising that to understand the extent of US power...a president must also map its limits." That dictum defines the way Obama makes the case for free speech, equality, accountable government. Here is the frame he placed around that advocacy in his opening remarks in Shanghai:

1. Assert mutual dependence and affirm the benefits of partnership.
2. Lay a foundation of respect for the audience's culture and history
3. Articulate the principles expressed in the United States' founding documents
4. Acknowledge American imperfection in pursuit of those principles
5. Catalog the benefits that have accrued to the U.S. by pursuing those principles
6. Acknowledge the shared pedigree of the principles; they are not merely American
7. Assert their universality
8. Connect political/intellectual freedom to free markets
9. Assert that the U.S. can/must learn from China (as well as implicitly 'teach' human rights).

Note how these factors work (and come full circle) in the heart of Obama's speech:

1. It is no coincidence that the relationship between our countries has accompanied a period of positive change. 2. China has lifted hundreds of millions of people out of poverty -- an accomplishment unparalleled in human history -- while playing a larger role in global events. 1.And the United States has seen our economy grow along with the standard of living enjoyed by our people, while bringing the Cold War to a successful conclusion.

2. There is a Chinese proverb: "Consider the past, and you shall know the future." Surely, we have known setbacks and challenges over the last 30 years. Our relationship has not been without disagreement and difficulty. 1. But the notion that we must be adversaries is not predestined -- not when we consider the past. Indeed, because of our cooperation, both the United States and China are more prosperous and more secure. We have seen what is possible when we build upon our mutual interests, and engage on the basis of mutual respect.

And yet the success of that engagement depends upon understanding -- on sustaining an open dialogue, and learning about one another and from one another. For just as that American table tennis player pointed out -- we share much in common as human beings, but our countries are different in certain ways.

I believe that each country must chart its own course. 2.China is an ancient nation, with a deeply rooted culture. The United States, by comparison, is a young nation, whose culture is determined by the many different immigrants who have come to our shores, and by the founding documents that guide our democracy.

3. Those documents put forward a simple vision of human affairs, and they enshrine several core principles -- that all men and women are created equal, and possess certain fundamental rights; that government should reflect the will of the people and respond to their wishes; that commerce should be open, information freely accessible; and that laws, and not simply men, should guarantee the administration of justice.

4. Of course, the story of our nation is not without its difficult chapters. In many ways -- over many years -- we have struggled to advance the promise of these principles to all of our people, and to forge a more perfect union. We fought a very painful civil war, and freed a portion of our population from slavery. It took time for women to be extended the right to vote, workers to win the right to organize, and for immigrants from different corners of the globe to be fully embraced. Even after they were freed, African Americans persevered through conditions that were separate and not equal, before winning full and equal rights.

5. None of this was easy. But we made progress because of our belief in those core principles, which have served as our compass through the darkest of storms. That is why Lincoln could stand up in the midst of civil war and declare it a struggle to see whether any nation, conceived in liberty, and "dedicated to the proposition that all men are created equal" could long endure. That is why Dr. Martin Luther King could stand on the steps of the Lincoln Memorial and ask that our nation live out the true meaning of its creed. That's why immigrants from China to Kenya could find a home on our shores; why opportunity is available to all who would work for it; and why someone like me, who less than 50 years ago would have had trouble voting in some parts of America, is now able to serve as its President.

6., 7. And that is why America will always speak out for these core principles around the world. We do not seek to impose any system of government on any other nation, but we also don't believe that the principles that we stand for are unique to our nation. These freedoms of expression and worship -- of access to information and political participation -- we believe are universal rights. They should be available to all people, including ethnic and religious minorities -- whether they are in the United States, China, or any nation. 8. Indeed, it is that respect for universal rights that guides America's openness to other countries; our respect for different cultures; our commitment to international law; and our faith in the future.

These are all things that you should know about America. 9. I also know that we have much to learn about China. Looking around at this magnificent city -- and looking around this room -- I do believe that our nations hold something important in common, and that is a belief in the future. Neither the United States nor China is content to rest on our achievements. For while China is an ancient nation, you are also clearly looking ahead with confidence, ambition, and a commitment to see that tomorrow's generation can do better than today's.

2. In addition to your growing economy, we admire China's extraordinary commitment to science and research -- a commitment borne out in everything from the infrastructure you build to the technology you use. China is now the world's largest Internet user -- which is why we were so pleased to include the Internet as a part of today's event. This country now has the world's largest mobile phone network, and it is investing in the new forms of energy that can both sustain growth and combat climate change -- and I'm looking forward to deepening the partnership between the United States and China in this critical area tomorrow. But above all, I see China's future in you -- young people whose talent and dedication and dreams will do so much to help shape the 21st century.

1. I've said many times that I believe that our world is now fundamentally interconnected. The jobs we do, the prosperity we build, the environment we protect, the security that we seek -- all of these things are shared. And given that interconnection, power in the 21st century is no longer a zero-sum game; one country's success need not come at the expense of another. And that is why the United States insists we do not seek to contain China's rise. 2. On the contrary, we welcome China as a strong and prosperous and successful member of the community of nations -- a China that draws on the rights, strengths, and creativity of individual Chinese like you.

To return to the proverb -- consider the past. 1.,2. We know that more is to be gained when great powers cooperate than when they collide. That is a lesson that human beings have learned time and again, and that is the example of the history between our nations. And I believe strongly that cooperation must go beyond our government. It must be rooted in our people -- in the studies we share, the business that we do, the knowledge that we gain, and even in the sports that we play. And these bridges must be built by young men and women just like you and your counterparts in America.

It may be an obvious message, but there's power in the simple assertion: "We do not seek to contain China's rise." That statement "contains" the doctrine of containment, which has been the dominant fact of geopolitics since the end of World War II. The message is that "containment" is directed at malignantly aggressive political forces, not at rival powers by simple virtue of their gaining power. It makes explicit Obama's broadest message: that democratic capitalism is not zero sum, that future prosperity must be shared prosperity, and that ultimately, only through universal acknowledgment of rights and principles of government that Obama affirms as universal can shared prosperity be triggered.

There is a Fukuyaman faith here that China's pursuit of prosperity will lead it inevitably to democracy -- not laid down as a challenge, but planted as a seed of desire in the country's young.

"No one can describe a taste" - Why?

2009-11-14T09:38:00.000-08:00

Via Andrew Sullivan, Jonah Lehrer channels Proust to explore why smells (and tastes) are so emotionally laden:

Why is smell so sentimental? One possibility, which is supported by this recent experiment, is that the olfactory cortex has a direct neural link to the hippocampus. In contrast, all of our other senses (sight, touch and hearing) are first processed somewhere else - they go to the thalamus - and only then make their way to our memory center. This helps explain why we're so dependent on metaphors to describe taste and smell. We always describe foods by comparing them to something else, which we've tasted before. ("These madeleines taste just like my grandmother's madeleines!" Or: "These madeleines taste like the inside of a lemon poppy seed cake!") In contrast, we have a rich language of adjectives to describe what we see and hear, which allows us to define the sensory stimulus in lucid detail. As a result, we don't have to lean so heavily on simile and comparison.

C.S. Lewis, in the final Narnia chronicle The Last Battle, casually delivers a different (though not really contradictory) explanation for why we depend on metaphors to describe taste and smell. When his newly-dead protaganists taste the first fruits of paradise, Lewis writes:

What was the fruit like? Unfortunately, no one can describe a taste. All I can say is that, compared with those fruits, the freshest grapefruit you've ever eaten was dull, and the juiciest orange was dry, and the most melting pear was hard and woody, and the sweetest wild strawberry was sour (Ch. 13, my emphasis).

So according to CSL, it's not that we're less inclined to create descriptive language about taste and smell: for some reason we just can't.

Why is that? We generally describe taste and smell, as Lehrer suggests via Proust, by reference to another taste or smell. But isn't the same true of sight? Start with colors: each color name is a giant analogy -- or scientifically speaking, a classification, grouping objects the surfaces of which really do reflect light in the same range of the spectrum. In fact, re that "rich language of adjectives" we use for sight and hearing -- every adjective is a compressed or aggregated simile or analogy, a classification.

I think that we describe sights more precisely than smells and tastes not because smell and taste are more emotionally laden but because they're less precise senses than sight. (Maybe because of some processing in that trip to the thalamus that smells don't make?) You can say of a tree's appearance that it's thirty feet tall, has a spear-shaped leaf crown, reddish bark in fishlike scales, and needle foliage; all you can say about the experience of eating a grapefruit is that it tastes like a more sour orange and smells fragrant and pungent. All language is ultimately relative, comparative -- but our range of comparison is much richer with visual data.

Dogs are supposed to rely far less on sight and more on smell than humans. I have a blind dog, half beagle to boot, and I can report that although he gets along pretty well, even for a dog smell is no substitute for sight.

While he'll always find food that you toss him, he does it by elaborate, slow elimination -- and he can walk right over it, more than once, before putting his nose (and mouth) to it. Smell is time-limited: when someone runs by he gets very excited, but he has no idea where they are. His hearing actually seems like a nearer sight-substitute than his sense of smell: when he's chasing a bouncing ball you'd think he could see until the bouncing noise stops, at which point he's relatively helpless.

Smell and taste may go straight to our emotional core. But their superior impact seems part and parcel with inferior discernment.

The incredible shrinking Afghan surge

2009-11-11T19:14:00.000-08:00

There was once a series of Peanuts comics in which Snoopy reflected on a tussle with a cat (who ripped him to shreds). In each comic, Snoopy doubled the weight of his antagonist -- that 50-pound cat, that 100-pound cat, that 200-pound cat (if memory serves...).

Something of the opposite seems to be happening in newspaper reports of Obama's "final" decision on a troop surge in Afghanistan. Two days ago, CBS News reported an "exclusive" that Obama had decided on 40,000 additional troops. The White House furiously denied it. Yesterday, the Times' Elisabeth Bumiller reported that Gates, Mullen and Clinton were "coalescing around a proposal to send 30,000 or more additional American troops." Now, this evening (Nov. 11), Bumiller and Mark Landler are out with a story claiming that Obama and team "have begun examining an option that would send relatively few troops to Afghanistan, about 10,000 to 15,000, with most designated as trainers for the Afghan security forces," prompted in some degree by reservations expressed by Karl Eikenberry, current U.S. ambassador to Afghanistan and once the top U.S. commander there.

As a complement, the Times also reports tonight something I've long suspected - that much of this angst is choreographed to put some pressure on Karzai and his government. Noting that the U.S. in one sense has precious little leverage, Helene Cooper reports:

Officials said Mr. Obama’s Afghanistan review took weeks longer than expected in part because officials were unhappy about reports of fraud in the Afghan elections, and they implied that even after the new Afghan strategy is announced, details will not be final.

“I’m not saying that we’ll be in a perpetual state of review, but the time the president has taken so far should signal to people that he will not hesitate to take a hard look at things and question assumptions if things are not moving in the right direction,” a senior White House official said.

Indeed, an AP story by Ben Feller and Anne Gearan, which claims that Obama has rejected all options presented to him in their current form, suggests a search for further leverage in the crevices of troop deployment:

But the president raised questions at a war council meeting Wednesday that could alter the dynamic of both how many additional troops are sent to Afghanistan and what the timeline would be for their presence in the war zone, according to the official, who spoke on condition of anonymity to discuss Obama's thinking.
Military officials said Obama has asked for a rewrite before and resisted what one official called a one-way highway toward war commander Gen. Stanley McChrystal's recommendations for more troops. The sense that he was being rushed and railroaded has stiffened Obama's resolve to seek information and options beyond military planning, officials said, though a substantial troop increase is still likely...
The key sticking points appear to be timelines and mounting questions about the credibility of the Afghan government. Administration officials said Wednesday that Obama wants to make it clear that the U.S. commitment in Afghanistan is not open-ended.

Leverage, leverage, leverage. Cooper's story suggests a search in other directions:

While they declined to go into many specifics, the officials, speaking on the condition of anonymity because the Afghanistan review is not complete yet, said they had a range of diplomatic, financial and economic options if the targets were not met.

One lever, they said, would be to shift money from Mr. Karzai’s central government to provincial leaders who perform better than their national counterparts. And although a complete withdrawal of American troops is not considered an option, Mr. Obama might endorse a partial withdrawal that would lead to a more limited counterinsurgency strategy initially advocated by Vice President Joseph R. Biden, Jr.

It would seem that Obama wants Karzai in a Skinner box. At the same time, he does not sound like a man preparing to disengage.

David Leonhardt tries to do Obama's job for him, part II

2009-11-11T05:41:00.000-08:00

David Leonhardt continues to do yeoman's work explaining the stakes and outlining the means of health care cost control. Today he compares cost control measures in the House bill, which he finds wanting, with those in the Senate Finance Committee bill, which are stronger. His main theme: that the true test of the Obama Administration's leadership comes now, in the endgame, in the skill and force with which they push for the most promising cost control measures.

Perhaps the single most telling flashpoint, according to Leonhardt, will be the fate of the so-called "MedPAC on Steroids," a commission empowered to make a yearly package of Medicare cost control recommendations to Congress, which Congress would have to vote up or down as a package. Leonhardt calls a commission thus empowered a "Fed for Health" to emphasize the need for political insulation. "Whether one ends up in the final bill," he writes, "will be a good test of Mr. Obama's endgame leadership."

Obama would seem to agree with Leonhardt. Back in July, he highlighted the commission as a a potential guiding light for cost control over the course of years and decades, telling Fred Hiatt:

At this point, I am confident that both the House and the Senate bills will contain what we've been calling MedPAC on steroids, the idea that you continually present new ideas to change incentives, change the delivery system, understanding that because this is such a complex system we're not always going to get it exactly right the first time, and that there have to be a series of modifications over the course of a series of years, and we have to take that out of politics and make sure that an independent board of medical experts and health economists are providing packages that are continually improving the system. So I think there's general consensus that that is one of two very powerful levers to bend the cost curve.

As for the second "lever":

Now, the second idea, which is the one that got more attention, even though Elmendorf, I think, has emphasized the benefits of a MedPAC board, as well, was the elimination of the tax exclusion [on employer-provided health insurance]. And I've been very clear on my position that I think to add additional costs to families right now when they're already seeing their premiums doubled is not the kind of health reform that I'd like to see, but I believe that there may be ways of getting at the same principle.

For example, you could conceivably set up an index of some sort that makes sure that health care inflation -- or to make sure that the exclusion only accommodates a certain amount of health care inflation -- as opposed to 8 percent or 9 percent, or what have you -- without burdening current plans, but over time assuming -- if we're assuming that health care inflation is going to continue to be a problem, that you could get at the problem in that way.

Hiatt: A kind of cap, but one that doesn't hurt anybody --

Obama: Currently.

Hiatt: -- at the current level?

Obama: Exactly. You're also seeing, I think, some interesting discussions in the Senate Finance Committee about a variation that goes after the insurance companies, as opposed to directly taxing the benefits.

That "variation that goes after insurance companies" is in the Senate Finance Committee bill, in the form of a surtax on plans that cost more than $21k per family and $8k per individual. "Along with the Medicare commission," according to Leonhardt, "this tax is the biggest single difference between the Senate and House versions. "

So Leonhardt has highlighted the degree to which the White House is in sync with Senate Finance on cost control, and the key cost control omissions in the House bill.

On the other side of the ledger, the House bill provides more generous coverage than the Senate Finance bill. Many who embrace the basic architecture of the Democrats' health reform efforts dream of a bill that combines House coverage with Senate cost control. Deep pessimism about the way Congress works in this era leads many to supsect that we'll get the opposite. I would bet on a mixed scorecard - maybe 1-for-2 on the excise tax and MedPAC, or both surviving in weakened form, and somewhat more generous subsidies with a stiffer coverage mandate than the Finance bill provides.

If a bill passess at all. The abortion pound of flesh extracted in the House, the weak majority with which the bill passed, Lieberman's grandstanding on the public option...all have made me wonder.

See also: David Leonhardt tries to do Obama's job for him (Part I)

Obama at Fort Hood: Embracing 'The Long War'?

2009-11-10T17:19:00.000-08:00

The President at Fort Hood today did not sound like a man planning to scale back American military commitments:

This generation of soldiers, sailors, airmen, Marines and Coast Guardsmen have volunteered in a time of certain danger. They are part of the finest fighting force that the world has ever known. They have served tour after tour of duty in distant, different and difficult places. They have stood watch in blinding deserts and on snowy mountains. They have extended the opportunity of self-government to peoples that have suffered tyranny and war. They are man and woman; white, black, and brown; of all faiths and stations – all Americans, serving together to protect our people, while giving others half a world away the chance to lead a better life.
In today's wars, there is not always a simple ceremony that signals our troops' success – no surrender papers to be signed, or capital to be claimed. But the measure of their impact is no less great – in a world of threats that know no borders, it will be marked in the safety of our cities and towns, and the security and opportunity that is extended abroad. And it will serve as testimony to the character of those who serve, and the example that you set for America and for the world.
Here, at Fort Hood, we pay tribute to thirteen men and women who were not able to escape the horror of war, even in the comfort of home. Later today, at Fort Lewis, one community will gather to remember so many in one Stryker Brigade who have fallen in Afghanistan.
Long after they are laid to rest – when the fighting has finished, and our nation has endured; when today's servicemen and women are veterans, and their children have grown – it will be said of this generation that they believed under the most trying of tests; that they persevered not just when it was easy, but when it was hard; and that they paid the price and bore the burden to secure this nation, and stood up for the values that live in the hearts of all free peoples.

There is nothing jingoistic or chauvinistic about this. But note the assertions of linked fate: to protect our people, while giving others half a world a way the chance to live a better life....But the measure of their impact is no less great – in a world of threats that know no borders, it will be marked in the safety of our cities and towns, and the security and opportunity that is extended abroad.

Note also the verb tense sequence: perfect (past leading to present moment), present continuous, and a use of the future that is thematically akin to the future perfect -- looking back at the present from a time ahead. There's a grammatical fusion of his own administration's commitments with Bush''s and perhaps with those of presidents to come.

Note too, that like Shakespeare Henry V before the battle of Agincourt, Obama pulls the commander-in-chief trick of inviting the men to envision their future satisfaction in a triumph that has yet to happen:

He that outlives this day, and comes safe home,

Will stand a tip-toe when this day is nam'd,

And rouse him at the name of Crispian...

This story shall the good man teach his son;

And Crispin Crispian shall ne'er go by,

From this day to the ending of the world,

But we in it shall be remembered-

We few, we happy few, we band of brothers...(HV IV, iii).

Perhaps Obama has absorbed Gates' concept of "the long war" -- which, Gates told West Point in April'08, "is likely to be many years of persistent, engaged combat all around the world in differing degrees of size and intensity," adding, "This generational campaign cannot be wished away or put on a timetable."

Gates moderates an expansive sense of mission with a determination to leverage allies, aid and diplomacy to leverage a minimalist use of military force. In an article outlining his strategic vision in Foreign Affairs (Jan/Feb '09, no longer available free), he wrote:

What is dubbed the war on terror is, in grim reality, a prolonged, worldwide irregular campaign -- a struggle between the forces of violent extremism and those of moderation. Direct military force will continue to play a role in the long-term effort against terrorists and other extremists. But over the long term, the United States cannot kill or capture its way to victory. Where possible, what the military calls kinetic operations should be subordinated to measures aimed at promoting better governance, economic programs that spur development, and efforts to address the grievances among the discontented, from whom the terrorists recruit. It will take the patient accumulation of quiet successes over a long time to discredit and defeat extremist movements and their ideologies.

In one sense, this mission is unexceptionable, as the U.S. will doubtless continue to attempt to foster development and democracy throughout the non-rich, nondemocratic world. The hard questions have to do with means -- with the assumption of a "prolonged, worldwide" military campagin . Rory Stewart, Afghan minimalist, wants to foster better governance and development in Afghanistan - he just wants to do it with 20,000 troops and selective, decentralized aid, rather than with 100,00 and a client state relationship. Stewart mocks maximalist assumptions like those expressed by Gates - that with the right combination of tools the U.S. can drain every failed-state swamp where terror breeds.

Obama certainly shares Gates' sense of the scope of the U.S. role in the world, as well as his predilection to "subordinate" military effort to diplomacy and aid. But is he signed up for "the long war"? It's starting to look that way.

Gates whistles past the graveyard of empires

2009-11-09T09:53:00.000-08:00

Robert Gates does not think that sending more troops toAfghanistan will put the U.S. on course to replay the Soviet disaster. He recently told Mike Crowley:

“I heard General McChrystal when he says it’s not so much the size of the footprint as how you use those troops, and I accept that. I think that’s right.”

“It’s also important to realize that the Soviets carried out a war of terror against the Afghan people,” he continued. “I mean, they killed a million, probably made five million refugees, and no country in the world supported what they were doing. We have a completely different situation in all those categories right now. They also tried to impose an alien culture and social order on the Afghans that was completely contrary to their history and culture. So I think the important thing is, as we look at the Soviet experience, to draw the right lessons from it and not just automatically say that because they lost, everybody loses.”

Though he wouldn’t discuss his advice to Obama with me, Gates has made several public comments that suggest a belief in a large troop presence. Speaking at a CNN roundtable discussion in early October, for instance, Gates warned against ceding large swaths of territory to the Taliban, as a counterterrorism strategy may entail. “There’s no question in my mind that, if the Taliban took large--took control of significant portions of Afghanistan, that that would be added space for Al Qaeda to strengthen itself,” Gates said. Such an outcome, he added, would be “hugely empowering” for Al Qaeda’s recruitment and fund-raising.

Steve Coll has picked apart the Soviet analogy in more detail:

By comparison to the challenges facing the Soviet Union after it began to "Afghanize" its strategy around 1985 and prepare for the withdrawal of its troops, the situation facing the United States and its allies today is much more favorable. Afghan public opinion remains much more favorably disposed toward international forces and cooperation with international governments than it ever was toward the Soviet Union. The presence of international forces in Afghanistan today is recognized as legitimate and even righteous, whereas the Soviets never enjoyed such support and were unable to draw funds and credibility from international institutions. China today wants a stable Afghanistan; in the Soviet era, it armed the Islamic rebels. The Pakistani Army today is divided and uncertain in its relations with the Taliban, and beginning to turn against them; during the Soviet period, the Army was united in its effort to support Islamist rebels. And even if the number of active Taliban fighters today is on the high side of published estimates, those numbers pale in comparison to the number of Islamic guerrillas fighting the Soviet forces and their Afghan clients.
In other words, the project of an adequately stable Afghan state free from coercive Taliban rule for the indefinite future can be achieved, although there are no guarantees.

On the other hand, Coll himself has elsewhere pointed to aspect of the Soviet experience in Afghanisan that remain dauntingly relevant:

The Soviets failed in Afghanistan for many reasons, beginning with the brutality of their military campaigns and the implausibility of their political strategy. Nonetheless, by the end of the 1980s, they had constructed a durable ink spot strategy, albeit one based on a more defensive and internally ruthless political-military strategy from the one McChrystal is proposing. The Soviets were unable, however, to convert that partial territorial achievement into a broader and more durable strategic success. Partly they just ran out of time, as often happens in expeditionary wars. Their other problems included their inability to control the insurgents’ sanctuary in Pakistan; their inability to stop infiltration across the Pakistan-Afghan border; their inability to build Afghan political unity, even at the local level; their inability to develop a successful reconciliation strategy to divide the Islamist insurgents they faced; and their inability to create successful international diplomacy to reinforce a stable Afghanistan and region. Does that list of headaches sound familiar?

One more headache: today the Taliban seems as well-funded by Arab money as it was with our help in the 1980s. One current operative recently reminisced to Newsweek:

YOUNAS: After these first few attacks [by the Taliban, as their resistance to the Kabul government picked up force], God seems to have opened channels of money for us. I was told money was flowing from the Gulf to the Arabs.

The money flow; the Pakistani sanctuary; the uncertain role of the ISI; the rampant corruption and deeply compromised legitimacy of the Kabul government...the barriers to fostering an Afghan government that can maintain anything like a state monopoly on violence provide plenty of fodder for quagmire anxiety

Then, too, while Gates suggests that the U.S. is not trying to "impose an alien culture and social order on the Afghans" many critics consider a U.S.-led attempt to institute democracy, fight corruption and establish central governmental authority throughout the country as doing just that. See, e.g., Matthew Hoh...

Owens' win in NY 23: bad for Democrats, good for the country?

2009-11-08T07:51:00.000-08:00

After basking a bit in the tea partiers' election-night shock when their insurgent darling Doug Hoffman went down in NY District 23, Frank Rich cautions:

The Democrats’ celebration was also premature: Hoffman’s defeat is potentially more harmful to them than to the Republicans....it increases the odds that the Republicans will not do Democrats the great favor of committing suicide between now and the next Election Day.

Quite so. But what may be bad for Democrats in the short term is good for the country.

The country needs the Republican party to step back from the brink. Other mature democracies have fringe parties that play primarily to voters' fears and fantasies, but those parties exist within multiparty systems. In times of stress their vote may approach or crack 20% of the total, and everyone draws a breath and notes the electorate's anger.

We have only two national parties. If one of them shrinks to attract the affiliation of less than 30% of the electorate and retreats entirely into fringe party thinking and tactics, that's dangerous. The tea partiers' lies and paranoid fantasies; their demonization of a reform effort as incremental, cautious, and indeed historically Republican in its genesis as the pending health care bills; their glorification of the willful ignorance of Palin and Bachmann and their rapt attention to transparent demagogues like Beck and Limbaugh, is all fringe party behavior. Those who equate health insurance mandates or voluntary end of life counseling with fascism are themselves potential fascists -- demonizers of opposition, rabid advocates of torture, paranoid fantasists.

If that fringe entirely captures one of our two parties, the next big shock -- a world market collapse like that predicted by Roubini, a major terrorist attack -- could push such people into power. If, meanwhile, new Republican governors in purple states go to work with even a modicum of pragmatism -as Christie at least will have to do -- that could have a powerful demonstration effect for Republican decision-makers.

A question for the data-mining maestros

2009-11-08T07:11:00.000-08:00

Sucked in by an Organizing for America pitch for health care reform, I tripped over what seems to be a trick of fundraising art:

Amount

Credit Card

Why do the options bump from 25-50-100 to 220? What byte of microtargeting data is at work there? Did donor patterns indicate that for people donating $100, going up another $20 or $10 might be a psychological barrier, whereas for people at the $200 level a 10% bump-up triggers no hesitation? Does this bring in an extra 3% or 5%? How prevalent is this trick? Is there some accepted wisdom that you can slip one bump-up in the menu but not more?

What does Abdullah want?

2009-11-04T09:24:00.000-08:00

On Sunday, Abdullah said he would not participate in a runoff election that was bound to be fraudulent. He discouraged his supporters from taking to the streets in protest. In a press conference today, he insisted that he is not interested in being part of Karzai's government or in winning seats for his followers ("We are not going to deal...I am not interested") .

Today he also called the cancellation of the runoff "illegal" -- and suggested that there is no Afghan government for the U.S. and allies to credibly support:

Eight years down the road we still need more troops. In the absence of a credible, reliable, and legitimate partner, more soldiers, more resources are the only thing which will be resulted....

A government which in its formation is based on an illegal decision by a body, to hope that the second government would deliver in dealing with the corruption, issues of governance, [improving] security in this country, it sounds like an exaggeration.

Meanwhile, The Christian Science Monitor reports that northern Afghanistan, where Abdullah's power is based, is an emerging new front for the insurgency.

So what does Abdullah want at this point? And what would be his advice to Obama?

If I had to guess on little info, I'd say he wants substantial power in Karzai's government, notwithstanding his protestations --or Karzai's poor track record with regard to power sharing. But who am I to guess?

"The logical core of Matthew Hoh's resignation letter": a counterpoint to Fallows

2009-10-31T14:43:00.000-07:00

James Fallows has a post titled "The logical core of Matthew Hoh's resignation letter." Hoh is the former army captain and Iraq War veteran who just resigned in protest a position of responsibility in Afghanistan, warning that he "fail[s] to see the value or worth" of military support of the Afghan government.

Hoh's resignation is an act of courage and principle, and he sounds some resonant alarms. When I read his letter, I couldn't help but wonder what would have been the impact if Colin Powell had picked a propitious moment to do something similar.

However, I must disagree with Fallows. I do not think that the passage he identifies is the core of Hoh's argument, nor is it entirely logical. Here it is:

"I find specious the reasons we ask for bloodshed and and sacrifice from our young men and women in Afghanistan. If honest, our stated strategy of securing Afghanistan to prevent al-Qaeda resurgence or regrouping would require us to additionally invade and occupy western Pakistan, Somalia, Sudan, Yemen, etc. [My (Fallows') emphasis.] Our presence in Afghanistan has only increased destabilization and insurgency in Pakistan where we rightly fear a toppled or weakened Pakistani government may lose control of its nuclear weapons. However, again, to follow the logic of our stated goals we should garrison Pakistan, not Afghanistan. More so, the September 11th attacks, as well as the Madrid and London bombings, were primarily planned and organized in Western Europe; a point that highlights that the threat is not one tied to traditional geographic or political boundaries."

For starters, the claim that continuing U.S. efforts to fight the Taliban and prop up the Afghan government "would require us" to invade and occupy Somalia, Sudan, Yemen, etc. is a red herring (leave Pakistan aside for a moment). The unspoken assumption is that terrorist threats from all lawless states are equal, and/or that al Qaeda could host itself equally effectively from Somalia, Sudan or Yemen, in each of which it has operated. Steve Coll has, I think, countered this assumption effectively:

It is simply not true that all potential al Qaeda sanctuaries are of the same importance, now or potentially. Bin Laden and his No. 2, Ayman Al-Zawahiri, have a 30-year, unique history of trust and collaboration with the Pashtun Islamist networks located in North Waziristan, Bajaur, and the Northwest Frontier Province of Pakistan. It is not surprising, given this distinctive history, that al Qaeda's presumed protectors -- perhaps the Haqqani network, which provided the territory in which al Qaeda constructed its first training camps in the summer of 1988 -- have never betrayed their Arab guests.
These networks have fought alongside al Qaeda since the mid-1980s and have raised vast sums of money in Saudi Arabia and other Gulf states through their connections. They possess infrastructure -- religious institutions, trucking firms, criminal networks, preaching networks, housing networks -- from Kandahar and Khost Province, and from Quetta to Karachi's exurban Pashtun neighborhoods, that is either impervious to penetration by the Pakistani state or has coopted those in the Pakistani security services who might prove disruptive. It is mistaken to assume that Bin Laden, Zawahiri, or other Arab leaders would enjoy similar sanctuary anywhere else. In Somalia they would almost certainly be betrayed for money; in Yemen, they would be much more susceptible to detection by the country's police network. The United States should welcome the migration of al Qaeda's leadership to such countries.

Accepting Coll's argument -- and I'm sure that there are informed parties to the debate who don't -- narrows the main counterterrorism focus to Aghanistan and Pakistan. But it does not follow that the logic of U.S. engagement in Afghanistan suggests tat the U.S. should "invade and occupy" Pakistan, as Hoh claims. Pakistan is a different country, and requires a different approach. As Rory Stewart points out, Pakistan is a more dangerous habitat for al Qaeda precisely because it's a stronger state than Afghanistan, and at least a nominal ally, and we don't have license or capacity to "invade and occupy" it (thank God).

The fact that a strategy we're currently engaged in in Afghanistan won't work in Pakistan and can't be tried there doesn't suggest either that it can't work in Afghanistan or that some other strategy might not work in Pakistan. Coll sees the key to happier outcomes for the region, and more effective counterterrorism, to be economic development in Pakistan on a par with, say, India's.* Pakistan can't get there without going a long way toward peace with India -- a goal that the U.S. can only help further with a very light touch, if at all -- as Hillary's highly contentious recent visit indicates.

There is no question that designing and implementing a U.S. strategy that would help establish modicum of peace and prosperity in Afghanistan and Pakistan is devilishly complex and difficult. But that doesn't mean that the U.S. can abjure trying -- whatever level of military engagement in Afghanistan might help further that end. Nor does it mean that adding troops in Afghanistan entails "invading and occupying" Pakistan, let alone Somalia etc.

In my view the "logical core of Hoh's letter" -- and its strongest challenge to U.S. policy -- lies elsewhere. It's in his claim that US military engagement stimulates the insurgency -- the more U.S. engagement, the more the more stimulus, and the stronger the Taliban. This argument has several parts: 1) Pashtun identity requires resisting control by "urban, secular, educated and modern Afghanistan"; 2) foreign troops joined to a government representing that internal enemy further stimulate resistance; 3) the government to which the U.S. has yoked itself is hopelessly corrupt and predatory; and 4) the U.S. presence in Afghanistan destabilizes Pakistan.

That is a fearsome indictment -- especially since few would dispute that the dynamic Hoh outlines has been at work in recent years. McChrystal himself acknowledges these realities. From McChrystal's 8/30 assessment:

GiRoA [the Afghan government] and ISAF [the international force led by the US] have both failed to focus on this objective [understanding the choices the Afghan people make between government and insurgents]. The weakness of state institutions, malign actions of power-brokers, widespread corruption and abuse of power by various officials, and ISAF's own errors, have given Afghans little reason to support their government....A foreign army alone cannot beat an insurgency; the insurgency in Afghanistan requires an Afghan solution...All ethnicities, particularly the Pashtuns, have traditionally sought a degree of independence from the central government.

Where McChrystal differs from Hoh is in his conviction that the US military can change the dynamic by changing its own practice, strategy, and culture. That's where the road forks. He asserts that "the popular myth that Afghans do not want governance is overplayed," and that the U.S. military can win allegiance by making "protecting the population" its primary goal; by changing its "operating culture" to one "that puts the Afghan people first"; and by "building personal relationship with its Afghan partners and the protected population."

That's an oddly utopian program for a ferociously tough commander. Cheney would have had a field day with McChrystal's language four or five years ago, e.g., "All ISAF personnel must show respect for local cultures and customs and demonstrate intellectual curiosity about the people of Afghanistan." This from a man whose chief responsibility in Iraq was running assassination squads against al Qaeda. If he can sell this strategy, it's through a kind of Nixon to China authority.

We're in unchartered territory. McChrystal is calling for a counterinsurgency effort more nuanced, more sensitive, more self-sacrificing and more multifaceted than any in history. He and Petraeus et al are pivoting from a remarkable, if partial and perhaps even temporary, military success in Iraq. But that precedent is no more complete an analogy than those of Vietnam or the Soviets in Afghanistan.

*India has its own dangerous insurgencies to cope with, but these days the US doesn't get so exercised about Maoists. That's a strange irony of history. I sometimes wonder, while we're so preoccupied with Islamic jihad, what new malign ideology will burst out of nowhere to exploit the horrific tools of terror developed over the last 20 years, and seek to develop worse. UPDATE 11/1: today's Times has a front page story about India's Maoist insurgency -- and a pending 70,000-troop counterinsurgency effort.

Public option and public perception

2009-10-30T09:32:00.000-07:00

ABC News reports that according to its latest poll, more Americans prefer a health reform bill with a public option and no Republican support than a bill without a public option that attracts Republican support.

It's not surprising that more people would care about results than about process. And a majority does support a public option when that term is adequately defined within the question (as it is in the ABC/WaPo's basic question about the public option). Nonetheless, I suspect that many may not have precisely understood this particular question. Here's the wording:

"Which of these would you prefer – (a plan that includes some form of government-sponsored health insurance for people who can’t get affordable private insurance, but is approved without support from Republicans in Congress); or (a plan that is approved with support from Republicans in Congress, but does not include any form of government-sponsored health insurance for people who can’t get affordable private insurance)?"

How many of those who prefer "a plan with some form of government-sponsored health insurance..." fully grasp that the bipartisan alternative would provide government-subsidized access to private insurance in a government-structured exchange that retails plans with government-mandated minimum coverage terms?

I'm all in favor of the public option myself, because I think that for-profit health insurance is a travesty and that government monopsony (control over the pricing of services) is the only way to control costs and guarantee uniform coverage. But I don't think this poll question gets across the benefits that would remain available in a reform bill with no public option.

The power of presence

2009-10-30T07:24:00.000-07:00

I usually have little patience for pundits quoting their pastors (or other clerics). But I found myself unexpectedly moved by this from Goldblog:

To the extent that the Internet and the proliferation of long distance learning deprive us of being in the presence of charismatic, kind, scholarly people, it will be a tremendous loss. When a Hasid said that he traveled miles just to see how his master tied his shoes, he was expressing this beautiful idea. What we learn from a great teacher cannot be put into a book, because it is in a look, an inflection, a quirk of personality or a tossed off comment. The greatest human lessons are found in the power of presence.

The David Brooks "consensus": Bring back George W. Bush

2009-10-30T05:07:00.000-07:00

Reporters are often excoriated for relying on anonymous sources. I can understand why they often have to. But David Brooks takes this to another level. He's hiding behind an anonymous consensus.

Brooks tells us "I’ve called around to several of the smartest military experts I know" to get their take on Obama's deliberations over Afghan policy. These "several" have a mysteriously unified persona. They're very, very smart and experienced. And lo, they all have the same worry. And lo, it looks an awful lot like Brooks's:

They are not worried about his policy choices. Their concerns are more fundamental. They are worried about his determination.

In fact, this Brooks shadow cabinet longs for the return of George W. Bush:

But they do not know if he possesses the trait that is more important than intellectual sophistication and, in fact, stands in tension with it. They do not know if he possesses tenacity, the ability to fixate on a simple conviction and grip it, viscerally and unflinchingly, through complexity and confusion. They do not know if he possesses the obstinacy that guided Lincoln and Churchill, and which must guide all war presidents to some degree.

The unanimous chorus is mysteriously sanguine about the odds of defeating the Taliban:

Most of them, like most people who have spent a lot of time in Afghanistan, believe this war is winnable. They do not think it will be easy or quick. But they do have a bedrock conviction that the Taliban can be stymied and that the governments in Afghanistan and Pakistan can be strengthened.

"Most" of "several" believe this? Right, there's consensus among the informed about staying the course. Funny that Andrew Exum -- who helped prepare General McChrystal's report, who does support the counterinsurgency effort, and who could in fact be one of Brook's sources, writes

I know about 50 really smart people on Afghanistan with lots of time on the ground there, and no two have the same opinion about what U.S. policy should be.

Brooks does voice a set of concerns worth considering:

...if these experts do not know the state of President Obama’s resolve, neither do the Afghan villagers. They are now hedging their bets, refusing to inform on Taliban force movements because they are aware that these Taliban fighters would be their masters if the U.S. withdraws. Nor does President Hamid Karzai know. He’s cutting deals with the Afghan warlords he would need if NATO leaves his country.

On the other hand, as several informed parties, e.g. Matthew Hoh and Rory Stewart, have noted, there's considerable evidence that ramped-up U.S. military presence, far more than presidential deliberations, drives Afghan villagers to support the Taliban. And as Joe Klein has noted, Obama's very public pause is in part calibrated to pressure Karzai, who's been "cutting deals with Afghan warlords" since he was first elected/installed. Indeed, going forward, Exum suggests (in a piece aptly titled Take Your Sweet Time, Obama):

The Obama adminstration has, I believe, some leverage at the moment, which it could use to affect the composition and behavior of the next Afghan government. As long as Afghanistan’s ruling politicians—Hamid Karzai especially—think the United States might reduce its commitment to Afghanistan, they could be willing to accede to U.S. demands on key ministerial and provincial-level appointments....

while countless memoranda and manuals exist instructing U.S. servicemen on how to wage counterinsurgency campaigns at the operational and tactical levels, there is currently little guidance for how U.S. policymakers should use leverage over its Afghan partners. The Obama administration, if it's clever, will try to figure out the best way to use its leverage over Karzai and other Afghan politicians. And in that effort, they deserve time to succeed.

David Brooks purports not to trust the President. I do not trust David Brooks. I think the opinions he "reports" represent 57% of seven people he selectively elected to represent consensus, their musings massaged into unison by Brooks's authoritative editorial "they."

I do not fear that Obama will prove ultimately to lack "conviction" in his search for a policy that works in Afghanistan. I do fear that the powerful institutional forces of U.S. post World War II foreign policy consensus -- forces that shaped the policy of every President from Truman through Clinton, more for good than not -- will work with our latter-day polarized political shriekfest to constrain Obama into a full-blown counterinsurgency effort.

That effort might be the right choice. But politically -- and paradoxically, since public opinion is turning agains the war -- it's hard to see any President really putting on the brakes in mid-course.

Related posts:
Steve Coll vs. Rory Stewart
Obama to Karzai: No marriage no dowry?
David Brooks' lazy free market fantasy

Holbrooke hearts Hoh in mid-resignation

2009-10-28T06:42:00.000-07:00

The resignation of Matthew Hoh, a bright young U.S. administrative official (and former Marine captain) in Afghanistan, is sobering, because he details ways in which the U.S. presence stimulates insurgency. To veer off what admittedly should be the focal point, though -- Hoh's argument against a large military footprint -- one thing that struck me in the Post's coverage was the reaction of senior officials, particularly Holbrooke, to his resignation letter:

The reaction to Hoh's letter was immediate. Senior U.S. officials, concerned that they would lose an outstanding officer and perhaps gain a prominent critic, appealed to him to stay.

U.S. Ambassador Karl W. Eikenberry brought him to Kabul and offered him a job on his senior embassy staff. Hoh declined. From there, he was flown home for a face-to-face meeting with Richard C. Holbrooke, the administration's special representative for Afghanistan and Pakistan.

"We took his letter very seriously, because he was a good officer," Holbrooke said in an interview. "We all thought that given how serious his letter was, how much commitment there was, and his prior track record, we should pay close attention to him."

While he did not share Hoh's view that the war "wasn't worth the fight," Holbrooke said, "I agreed with much of his analysis." He asked Hoh to join his team in Washington, saying that "if he really wanted to affect policy and help reduce the cost of the war on lives and treasure," why not be "inside the building, rather than outside, where you can get a lot of attention but you won't have the same political impact?"

Can you imagine how the Bush Administration would have reacted to such a resignation? They probably would have blacklisted Hoh, smeared him, perhaps had him prosecuted on some trumped up charge.

Holbrooke's reaction recalls his recruitment practices as related in George Packer's recent New Yorker profile:

One night in April, Holbrooke was on the last Delta shuttle from Washington to New York when Rina Amiri recognized him. An Afghan-American woman in her thirties, Amiri came from a royalist family in Kabul that had fled to America when the Afghan king Zahir Shah was overthrown, in 1973; since 2001, she had been working in Afghanistan on political and human-rights issues, for the U.N. and then the Open Society Institute. Amiri sat in the row behind Holbrooke and pressed him about a constitutional problem related to the Afghan elections. After a few minutes, Holbrooke suddenly said, “You know, I’m building this team.”
“I know,” Amiri said. “But I’m here to lobby you.”
“I’m very efficient. I just turned your lobbying into a job interview.” Holbrooke fixed her with a steady look. “Do you realize no one will offer you the type of opportunity I’m offering to affect your country?”
She asked him for more specifics. “You will have a lot of latitude,” he said. “That’s the way I work.”
Amiri was wary of losing her independence. She also worried about Holbrooke’s reputation for abrasiveness. Would she be in a meeting in Kabul where her American boss pounded his fist on the table? It took a month, but eventually Holbrooke won her over, hiring her as an Afghanistan expert. (Henry Kissinger once said, “If Richard calls you and asks you for something, just say yes. If you say no, you’ll eventually get

Obama's best and brightest may well prove capable of disastrous miscalculation. But their mental habits are reassuring.

Oh for a health care monopsony

2009-10-27T12:12:00.000-07:00

Those who blame for-profit health insurers for high U.S. health care costs usually focus on administrative and marketing costs. As Ezra Klein has highlighted, however, these are difficult to calculate; they're not always significantly higher in the private sector than in the public; and they don't fly as a primary cause of the U.S.'s uniquely high per capita health care spending.

Yet our Balkanized health care payment system does have a huge impact on health care costs. Klein again, citing Kaiser Permanente CEO George Halvorson pointing out that CT scans cost about 3x as much in the U.S. as in Europe, links to a 2003 study published in Health Affairs ("It's the Prices, Stupid...", Gerard F. Anderson et al. ) analyzing why procedures cost so much more in the U.S. than in OECD countries with universal healthcare.

The conclusion of this study bears out T.R. Reid's reporting in The Healing of America. Countries with universal health care all accord government the power of monopsony - "a state in which demand comes from one source." That is, the governments of France, Germany, Japan, Canada and England all set the prices for every procedure (or patient, in a capitated system) -- regardless of whether or not payments are funneled through private (nonprofit) insurers. All of them, by American standards, squeeze doctors and hospitals. Anderson et al:

In the U.S. health system...money flows from households to the providers of health care through a vast network of relatively unccordinated pipes and capillaries of various sizes. Although the huge federal Medicare program and the federal-state Medicaid programs do possess some monopsonistic purchasing power, and large private insurers may enjoy some degree of monopsony power as well in some localities, the highly framented buy side of the U.S. health system is relatively weak by international standards. It is one factor, among others, that could explain the relatively high prices paid for health care and for health professionals in the United States.

In comparison, the government-controlled health systems of Canada, Europe, and Japan allocate considerably more market power to the buy side...

Even a pure monopsonist is ultimately constrained by market forces on the supply side -- that is, by the reservation (minimally acceptable) prices of the providers of health care below which they will not supply their goods or services. But within that limit, monopsonistic buyers enjoy enough market clout to drive down the prices paid for health care and health care inputs fairly close to those reservation prices. It can explain, for example, why Fuchs and Hahn found that "U.S. fees for procedures are more than three times as high as Canadian fees [and] the difference in fees for evaluation and management services is about 80 percent."

From this perspective, individual health insurance companies are not "to blame" for high U.S. health care costs. But the system that allows them to exist is. When the government abjures monopsony power, patients lose.

Doctors do consider themselves underpaid and in some cases overmanaged in monopsony systems. On the other hand, they generally have to cope with zero medical school debt, piddling malpractice insurance fees, and minimal administrative burdens (in France, where national health cards record every procedure and fee, the time and money doctors spend on administration is close to zero). Ironically, one reason U.S. insurers pay doctors and hospitals so much more than their rich country peers is that the balkanized payment and claims system imposes onerous admnistrative costs on providers.

Did Defoe really celebrate diversity? Yes

2009-10-26T06:48:00.000-07:00

As an antidote to Patrick Buchanan's racist dreams of a pure white America, Andrew Sullivan has thrice recently drawn on* a "once-celebrated 1703 poem from Daniel Defoe, "The True Born Englishman", written to counter the Buchanans of his day (and to defend a foreign-born king)." The poem is truly magnificent. Tracing the Brits' multiple ethnic infusions, it concludes:

A true-born Englishman’s a contradiction,
In speech an irony, in fact a fiction.

Reading it, I did wonder, however, whether Defoe was not mocking his country's "mongrel" makeup even as he mocked those who pretended otherwise. Eighteenth century satire often disappoints our current sensibilities in that way. These lines at least could be read as mockery:

From whence a mongrel half-bred race there came,

With neither name, nor nation, speech nor fame.

In whose hot veins new mixtures quickly ran,

Infus’d betwixt a Saxon and a Dane.

While their rank daughters, to their parents just,

Receiv’d all nations with promiscuous lust.

This nauseous brood directly did contain

The well-extracted blood of Englishmen.

The tone throughout is complex, simultaneously mocking and celebratory. Rather than mock-celebrating the messy reality, however, the poem mocks to celebrate. There's a kind of self-canceling exceptionalism: England is blessed because it encompasses everywhere. Ultimately, the celebration has a religious dimension. The Christian contradiction of God becoming man in a sense sacralizes the omnivorous lust that fuses conquered and conquerer:

Some think of England ’twas our Saviour meant,

The Gospel should to all the world be sent:

Since, when the blessed sound did hither reach,

They to all nations might be said to preach.

Moreover, while the author glossing his own lines should not be granted an absolute interpretative authority, Defoe did, in an "Explanatory Preface" to a later edition, definitively spell out an inclusive ideology:

For why should not our neighbours be as good as we to derive from? And I must add that, had we been an unmixed nation, I am of opinion it had been to our disadvantage. For, to go no further, we have three nations about us as clear from mixtures of blood as any in the world, and I know not which of them I could wish ourselves to be like—I mean the Scots, the Welsh and Irish; and if I were to write a reverse to the satire, I would examine all the nations of Europe, and prove that those nations which are most mixed are the best, and have least of barbarism and brutality among them.

Defoe's response to the nativism of his day is indeed fully relevant today:

From hence I only infer that an Englishman, of all men, ought not to despise foreigners as such, and I think the inference is just, since what they are to-day, we were yesterday, and to-morrow they will be like us. If foreigners misbehave in their several stations and employments, I have nothing to do with that; the laws are open to punish them equally with natives, and let them have no favour.

Also astonishingly contemporary is Defoe's defense of a foreign-born (Dutch) king -- as is the abuse heaped upon that imported chief executive:

Nor would I be misrepresented as to the ingratitude of the English to the King and his friends, as if I meant the English as a nation are so. The contrary is so apparent, that I would hope it should not be suggested of me; and, therefore, when I have brought in Britannia speaking of the King, I suppose her to be the representative or mouth of the nation as a body. But if I say we are full of such who daily affront the King and abuse his friends, who print scurrilous pamphlets, virulent lampoons, and reproachful public banter against both the King's person and Government, I say nothing but what is too true. And that the satire is directed at such I freely own, and cannot say but I should think it very hard to censured for this satire while such remained unquestioned and tacitly approved.

Next up: Robin Crusoe's tips for neocolonialist counterinsurgents. Sketchy memory tells me that this will not be as satisfying.

*See also Sullivan's Sunday Times column on the U.S.'s mixed ethnic heritage.

Did McChrystal (or Petraeus) Read Henry V?

2009-10-25T16:38:00.000-07:00

I was astonished to read in today's Times that the authors of the U.S. military's current counterinsugency doctrine are steeped in contemparary scholarship of the 100 Years' War (among many other conflicts).

Astonished, because apparently a bit of throwaway literary free association I indulged in last week, comparing McChrystal's articulation of how to win the local population's hearts and minds to that of Shakespeare's Henry V, apparently has some basis in reality.

I did wonder while writing the post whether Shakespeare's version of Henry's approach to "playing for a kingdom" by being "the gentler gamester" itself had any basis for in reality. The Times article indicates that it did:

...by the time Henry landed near the mouth of the Seine on Aug. 14, 1415, and began a rather uninspiring siege of a town called Harfleur, France was on the verge of a civil war, with factions called the Burgundians and the Armagnacs at loggerheads. Henry would eventually forge an alliance with the Burgundians, who in today’s terms would become his “local security forces” in Normandy, and he cultivated the support of local merchants and clerics, all practices that would have been heartily endorsed by the counterinsurgency manual.

Of course, Henry's aim, ruling a foreign country by remote control, would not be endorsed by the counterinsurgency manual - not consciously, anyway. But that's pretty much what critics of current and pending policy like Rory Stewart see the U.S. trying to do.

Steve Coll vs. Rory Stewart on the AfPak endgame

2009-10-22T16:24:00.000-07:00

In almost perfect counterpoise on Obama's excrutiating decision on how to proceed in Afghanistan and Pakistan are two supremely well-informed former sojourners in that country, Rory Stewart and Steve Coll. Stewart sees futlity in what he casts as neoimperialist attempts to shape an alien culture; Coll outlines with great authority the dangers of letting the Taliban thrive, and advocates working to foster an Afghan government that negotiates and governs its way to a measure of legitimacy and adequate authority. They are not quite opposites, since Stewart would not cede the country to the Taliban and Coll is cautious and noncommittal about the degree of military engagement. But they're on different sides of the midpoint.

Considering the linked or not-so-linked goals of neutralizing al Qaeda and stabilizing Afghanistan, both emphasize the swallow-the-spider-to-catch-the-fly nature of pursuing the latter goal as a means to the former. But Stewart ravels out the chain of goals to mock it, while Coll demonstrates pretty powerfully that the concantenations are real. Here's Stewart's irony:

Policymakers perceive Afghanistan through the categories of counter-terrorism, counter-insurgency, state-building and economic development. These categories are so closely linked that you can put them in almost any sequence or combination. You need to defeat the Taliban to build a state and you need to build a state to defeat the Taliban. There cannot be security without development, or development without security. If you have the Taliban you have terrorists, if you don’t have development you have terrorists, and as Obama informed the New Yorker, ‘If you have ungoverned spaces, they become havens for terrorists.’

Coll breaks this circularity by widening the chessboard. The key to Pakistani stability, he emphasizes, is peace with India:

American policy over the next five or 10 years must proceed from the understanding that the ultimate exit strategy for international forces from South Asia is Pakistan's economic success and political normalization, manifested in an Army that shares power with civilian leaders in a reasonably stable constitutional bargain, and in the increasing integration of Pakistan's economy with regional economies, including India's. Such an evolution will likely consolidate the emerging view within Pakistan's elites that the country requires a new and less self-defeating national security doctrine. As in the Philippines, Colombia, and Indonesia, the pursuit of a more balanced, less coup-ridden, more modern political-military order in Pakistan need not be complete or confused with perfection for it to gradually pinch the space in which al Qaeda, the Taliban, and related groups now operate. Moreover, in South Asia, outsiders need not construct or impose this modernizing pathway as a neo-imperial project. The hope for durable change lies first of all in the potential for normalizing relations between Pakistan and India, a negotiation between elites in those two countries that is already well under way, without Western mediation, and is much more advanced than is typically appreciated. Its success is hardly assured, but because of the transformational effect such normalization would create, the effects of American policies in the region on its prospects should be carefully assessed.

Against this backdrop, a Taliban insurgency that increasingly destabilizes both Afghanistan and the border region with Pakistan would make such regional normalization very difficult, if not impossible, in the foreseeable future. Among other things, it would reinforce the sense of siege and encirclement that has shaped the Pakistan Army's self-defeating policies of support for Islamist militias that provide, along with a nuclear deterrent, asymmetrical balance against a (perceived) hegemonic India.

More directly to the point of how the U.S. should proceed in Afghanistan, Coll one by one recouples the delinkages of those who suggest the U.S. can 'contain' al Qaeda without working hard to foster a coherent state in Afghanistan. First, most arrestingly, he debunks the notion that chaos or Taliban rule in large swaths of Afghanistan and Pakistan don't matter much, because al Qaeda could find a haven in any of a number of failed or extremist states:

It is simply not true that all potential al Qaeda sanctuaries are of the same importance, now or potentially. Bin Laden and his No. 2, Ayman Al-Zawahiri, have a 30-year, unique history of trust and collaboration with the Pashtun Islamist networks located in North Waziristan, Bajaur, and the Northwest Frontier Province of Pakistan. It is not surprising, given this distinctive history, that al Qaeda's presumed protectors -- perhaps the Haqqani network, which provided the territory in which al Qaeda constructed its first training camps in the summer of 1988 -- have never betrayed their Arab guests.
These networks have fought alongside al Qaeda since the mid-1980s and have raised vast sums of money in Saudi Arabia and other Gulf states through their connections. They possess infrastructure -- religious institutions, trucking firms, criminal networks, preaching networks, housing networks -- from Kandahar and Khost Province, and from Quetta to Karachi's exurban Pashtun neighborhoods, that is either impervious to penetration by the Pakistani state or has coopted those in the Pakistani security services who might prove disruptive. It is mistaken to assume that Bin Laden, Zawahiri, or other Arab leaders would enjoy similar sanctuary anywhere else. In Somalia they would almost certainly be betrayed for money; in Yemen, they would be much more susceptible to detection by the country's police network. The United States should welcome the migration of al Qaeda's leadership to such countries.

Coll also rebuts the notion that the Taliban might not shelter al Qaeda this time around:

It would also be mistaken to believe, as some in the Obama administration have apparently argued, that a future revolutionary Taliban government in Kabul, having seized power by force, might decide on its own or could be persuaded to forswear connections with al Qaeda. Although the Taliban are an amalgamation of diverse groupings, some of which have little or no connection to al Qaeda, the historical record of collaboration between the Haqqani network and al Qaeda, to choose one example, is all but certain to continue and probably would deepen during any future era of Taliban rule in Afghanistan. The benefits of a Taliban state to al Qaeda are obvious: After the Sept. 11 attacks, the United States gathered evidence that al Qaeda used Afghan government institutions as cover for import of dual-use items useful for its military projects. Reporters with the McClatchy newspaper group's Washington bureau recently quoted a senior U.S. intelligence official on this subject: "It is our belief that the primary focus of the Taliban is regional, that is Afghanistan and Pakistan. At the same time, there is no reason to believe that the Taliban are abandoning their connections to al Qaeda ... The two groups ... maintain the kind of close relationship that -- if the Taliban were able to take effective control over parts of Afghanistan -- would probably give al Qaeda expanded room to operate." This assessment is consistent with recent history.

Coll has a nuanced view of history. He sees the parallels between U.S. attempts to pacify Afghanisan and the Soviet debacle there, but also the differences:

By comparison to the challenges facing the Soviet Union after it began to "Afghanize" its strategy around 1985 and prepare for the withdrawal of its troops, the situation facing the United States and its allies today is much more favorable. Afghan public opinion remains much more favorably disposed toward international forces and cooperation with international governments than it ever was toward the Soviet Union. The presence of international forces in Afghanistan today is recognized as legitimate and even righteous, whereas the Soviets never enjoyed such support and were unable to draw funds and credibility from international institutions. China today wants a stable Afghanistan; in the Soviet era, it armed the Islamic rebels. The Pakistani Army today is divided and uncertain in its relations with the Taliban, and beginning to turn against them; during the Soviet period, the Army was united in its effort to support Islamist rebels. And even if the number of active Taliban fighters today is on the high side of published estimates, those numbers pale in comparison to the number of Islamic guerrillas fighting the Soviet forces and their Afghan clients.
In other words, the project of an adequately stable Afghan state free from coercive Taliban rule for the indefinite future can be achieved, although there are no guarantees.

He also debunks the cliche that a cohesive state in Afghanistan is an impossible dream because it has never happened before:

Nor does the project of an adequately intact, if weak and decentralized, Afghan state, require the imposition of Western imagination. Between the late 18th century and World War I, Afghanistan was a troubled but coherent and often peaceful independent state. Although very poor, after the 1920s it enjoyed a long period of continuous peace with its neighbors, secured by a multi-ethnic Afghan National Army and unified by a national culture. That state and that culture were badly damaged, almost destroyed, by the wars ignited by the Soviet invasion of 1979 -- wars to which we in the United States contributed destructively. But this vision and memory of Afghan statehood and national identity has hardly disappeared. After 2001, Afghans returned to their country from refugee camps and far flung exile to reclaim their state -- not to invent a brand new Western-designed one, as our overpriced consultants sometimes advised, but to reclaim their own decentralized but nonetheless unified and even modernizing country.

The range of Coll's historical perpective - that the U.S. is not the Soviet Union (though prone to some of the same kinds of errors), that a coherent Afghan state is not a pipe dream, that the AfPak badlands are al Qaeda's native environment -- is really priceless. Equally nuanced is his sense of the possibilities and limitations of political pressure informed by goals that are political in the deepest sense: peace between Pakistan and India, inter-ethnic engagement and negotiation by the Afghan government.

None of this deep knowledge and balanced perspective means that Coll is necessarily right about the prospects of in some recognizable sense "winning" in Afghanistan and Pakistan. But he's come closer than either Richard Holbrooke or Stanely McChrystal to articulating what success might look like -- and even how the U.S. and international community might help foster it.

Stewart's view is as complex, nuanced and informed as Coll's. He details the unlikeihood that the U.S. can defeat the Taliban outright; the equal unlikelihood that the Taliban could overrun the entire country; the impossiblity of "building" a central government whose writ extends in modern nation-state style across the entire country; and the paradox that a relatively strong state can be a more dangerous haven for the likes of al Qaeda than a weak one. He emphasizes what can't be done more than what can, and Coll does the opposite; but both see a mixed outcome and the possibility for limited cooperation/collaboration with the Afghan government, infused by humility.

But a fundamental difference remains. Coll defends assumptions and ultimately (if equivocally) embraces goals that Stewart sees as delusive:

The fundamental assumptions remain that an ungoverned or hostile Afghanistan is a threat to global security; that the West has the ability to address the threat and bring prosperity and security; that this is justified and a moral obligation; that economic development and order in Afghanistan will contribute to global stability; that these different objectives reinforce each other; and that there is no real alternative.

But why delusive? In the end, Stewart's critique devolves into literary criticism - an analysis of the syntax of two 19th century British statesmen with different world views. His preference for the language and world view of the skeptic is not an argument. He highlights many perhaps insurmountable difficulties of attaining the vision outlined above, but he stops short of really indicating how to attain a messy but viable alternative. Coll, in the end, engages facts on the ground more relentlessly.

UPDATE 11/1: In retrospect I don't think I did justice to Stewart's argument here, which is cleaner in his Senate testimony. His case for why Afghanistan is unlikely to achieve a reasonably unified national government any time soon is at least as detailed as Coll's to the contrary, as is his policy recommendation -- 20,000 troops, aid targeted to selected projects.

I do think that there's a logical flaw in one of Stewart's syllogisms: a) Afghanistan is 30 years behind Pakistan in state-building capacity; b) Pakistan is a worse danger to us than Afghanistan, precisely because it's a cohesive enough state to preclude full-scale US military engagement in its tribal havens for the Taliban and al Qaeda; c) we're actually better off with a weak Afghanistan than we'd be with a relatively strong one. That sequence ignores thae fact that Pakistan is so dangerous in large part because of the long Afghan Civil War and Pakistan's engagement with (creation of) the Taliban. Stewart lampoons the chicken-egg nature of arguments for counterinsurgency-as-counterterrorism, the interchangeability of alleged cause and effect But his attempt to pull the cause and effect chain straight is no more convincing than that of the counterinsuragent theorists.

More to come on this.

Obama to Karzai: No marriage, no dowry?

2009-10-19T07:40:00.000-07:00

I have noted before that at least since September 20 Obama has been signalling that the ostentatiously public review of Afghan strategy is at least in part an attempt to force a credible outcome -- most likely a unity government between Karzai and Abdullah -- to the fraudulent Afghan election. In his talk show blitz at that time, Obama recast the troop increase he ordered in March as a bid to secure the election and stressed that he had at that time planned a second review in the election's wake.

The point may seem obvious by now - how could the U.S. go all-in to support a government re-seated by an election so fraudulent it insistently recalls the bogus election in Iran? In any case, the linkage was made explicit by a chorus of administration officials and allies this weekend. From the Times' talk show roundup:

WASHINGTON — The White House signaled Sunday that President Obama would postpone any decision on sending more troops to Afghanistan until the disputed election there had been settled and resulted in a government that could work with the United States.

As an audit of Afghanistan’s Aug. 20 election ground toward a conclusion, American officials pressed President Hamid Karzai to accept a runoff vote or share power with his main rival, Abdullah Abdullah, a former foreign minister. Although Mr. Karzai’s support appeared likely to fall below 50 percent in the final count, together he and Mr. Abdullah received 70 percent, in theory enough to forge a unity government with national credibility.

The question at the heart of the matter, said President Obama’s chief of staff, Rahm Emanuel, is not “how many troops you send, but do you have a credible Afghan partner for this process that can provide the security and the type of services that the Afghan people need?” He appeared on CNN’s “State of the Union” and CBS’s “Face the Nation.”

He echoed the thoughts of Senator John Kerry of Massachusetts, a top Obama ally and the chairman of the Foreign Relations Committee, who said in a separate interview from Kabul, “I don’t see how President Obama can make a decision about the committing of our additional forces, or even the further fulfillment of our mission that’s here today, without an adequate government in place.” His interview was broadcast on “Face the Nation.”
“It would be irresponsible,” Mr. Emanuel told CNN. Then he continued, paraphrasing the senator, that it would be reckless to decide on the troop level without first doing “a thorough analysis of whether, in fact, there’s an Afghan partner ready to fill that space that U.S. troops would create and become a true partner in governing.”

Looks awfully like no shotgun marriage, no dowry.

UPDATE 10/27: Joe Klein (10/24) also sees Obama's pause as a conscious application of political pressure:

Rahm Emanuel's television appearance last Sunday, in which he said that no decision could be made on more troops until the Afghan government resolved its electoral mess, was part of a coordinated effort to get Karzai to agree to a runoff election. And it worked, but not before a baloney-storm erupted among the wingers, criticizing the President and Emanuel for dithering about sending more troops. As soon as Karzai agreed to the runoff, a second message was sent by Secretary of Defense Robert Gates--plans were proceeding for the next stage of the war. The Emanuel-Gates statements were routinely described as "dueling" and, for a day or so, that's exactly how it seemed: a slight breech between the Pentagon and the White House.

But it wasn't. And Obama's effort to formulate a new strategy for Afghanistan is, by all accounts, a coherent effort to incorporate four information streams--the military situation on the ground (the McChrystal stream); the military situation across the Pakistan border, where a major offensive is taking place that will have an impact on the situation in Afghanistan; the Afghan political stream; and the latest intelligence about the size, strength and intentions of Al Qaeda.

Up the Great Chain of Being with Mowlena Rumi

2009-10-18T11:23:00.000-07:00

One corner of my mind remains open to the possibility that mystics tap into something real. Here's a poem by the Sufi Mowlena Rumi (1207-1273) that seems pumped out of the central artery:

I died as mineral and became a plant.
I died as plant and rose as an animal.
I died as animal and I was Man.
Why should I fear? When was I less by dying?
Yet once more I shall die as Man to soar
With angels blest; but even from angelhood
I must pass on: "All save the face of God doth perish."
When I have sacrificed my angelic soul,
I shall become what no mind has ever conceived.
Oh, let me not exist! for nonexistence
Proclaims in organ tones: "To Him shall we return."

-- cited in Roy Mattadehedeh, The Mantle of the Prophet: Religion and Politics in Iran

"Let me not exist" -- a similar impulse was spun out a bit more than a century later (circa 1375) and a world apart in the anonymous English mystical primer The Cloud of Unknowing, which counsels the contemplative to seek a state in which

..in avoiding of all knowing He who is is always unknown he is knitted unto Him in the best manner; and in that he knows nothing, he is made to be knowing above mind.

Indeed, nonexistence, unknowing, erasure or dissolution of the self in the all-encompassing reality of God, is a staple of mysticism in many times and regions.

General McChrystal, the gentler gamester

2009-10-17T11:46:00.000-07:00

As chronicled in this week's Times Magazine profile, General Stanley McChrystal, commander of NATO forces in Afghanistan, is taking the current counterinsurgency imperative to win hearts and minds to a new level:

In his first weeks on the job, McChrystal issued directives instructing his men on how to comport themselves with Afghans (“Think of how you would expect a foreign army to operate in your neighborhood, among your families and your children, and act accordingly”); how to fight (“Think of counterinsurgency as an argument to win the support of the people”); even how to drive (“in ways that respect the safety and well-being of the Afghan people”). At the heart of McChrystal’s strategy are three principles: protect the Afghan people, build an Afghan state and make friends with whomever you can, including insurgents. Killing the Taliban is now among the least important things that are expected of NATO soldiers.

The approach to occupation is not exactly new. Compare Shakespeare's Henry V in the midst of his campaign to assert his sovereignty over France, approving the execution of his former friend Bardolph for stealing a holy tablet:

We would have all such offenders so cut off: and we
give express charge, that in our marches through the
country, there be nothing compelled from the
villages, nothing taken but paid for, none of the
French upbraided or abused in disdainful language;
for when lenity and cruelty play for a kingdom, the
gentler gamester is the soonest winner (III. vi. 107-113).

Henry did eventually win effective sovereignty over France, though he died before he could be crowned, and his adversary the French-born Charles VII was crowned in 1429 (thanks to the galvanizing tactics of mujahideen Joan of Arc), fourteen years after Henry's first invasion. The Brits were driven out for good in 1453 -- 38 years after this order to win hearts and minds was allegedly delivered in Picardy.

Obama (re) declares war on lobbyists

2009-10-17T08:52:00.000-07:00

It's on now. When the Baucus bill passed out of committee, it became clear that some form of health care reform will likely pass. That was the opening gong for lobbyists to start their final pushes to knock key cost control measures off of the end product -- the excise tax on expensive health care plans, the pending Sustainable Growth Rate cut to doctors' Medicare payments, the cuts in subsidies to Medicare Advantage plans, the tax on medical device makers, strong price control leverage for any public option, etc. etc.

The bogus and swiftly discredited (counter-swiftboated?) AHIP-commissioned study purporting to show that the Baucus bill will raise premiums was in turn a red cape to Democrats, who have gone out with gusto to paint the health insurance industry as public enemy #1. It is unlikely that AHIP is trying to prevent a reform bill from passing; they are rather trying to get what they can added in and taken out -- stiffer individual mandates, increased subsidies, no public option, no excise tax, weaker mimimum coverage standards. Give them all that, and reform is still worth doing -- insurance at least marginally worth having will still be made at least marginally affordable to most of those who now lack it. But the U.S. health care system will remain dysfunctional -- twice as expensive as that of other rich countries, riddled with coverage holes, wired for overtreatment. The battle now is about how eviscerated the final bill will be.

That is why Obama has returned to a major campaign theme: we can't reform our policies until we reform our politics. Here's how he put it on Jan. 30, 2008 in Denver:

we need to do more than turn the page on the failed Bush-Cheney policies; we have to turn the page on the politics that helped make those policies possible.

Lobbyists setting an agenda in Washington that feeds the inequality, insecurity, and instability in our economy.

Division and distraction that keeps us from coming together to deal with challenges like health care, and clean energy, and crumbling schools year after year after year.

Cronyism that gave us Katrina instead of competent government. And secrecy that made torture permissible and illegal wiretaps possible.

It's a politics that uses 9/11 to scare up votes; and fear and falsehoods to lead us into a war in Iraq that should've never been authorized and should've never been waged.

Compare his weekly address today:

This [rampant health care inflation] is the unsustainable path we’re on, and it’s the path the insurers want to keep us on. In fact, the insurance industry is rolling out the big guns and breaking open their massive war chest – to marshal their forces for one last fight to save the status quo. They’re filling the airwaves with deceptive and dishonest ads. They’re flooding Capitol Hill with lobbyists and campaign contributions. And they’re funding studies designed to mislead the American people.

Of course, like clockwork, we’ve seen folks on cable television who know better, waving these industry-funded studies in the air. We’ve seen industry insiders – and their apologists – citing these studies as proof of claims that just aren’t true. They’ll claim that premiums will go up under reform; but they know that the non-partisan Congressional Budget Office found that reforms will lower premiums in a new insurance exchange while offering consumer protections that will limit out-of-pocket costs and prevent discrimination based on pre-existing conditions. They’ll claim that you’ll have to pay more out of pocket; but they know that this is based on a study that willfully ignores whole sections of the bill, including tax credits and cost savings that will greatly benefit middle class families. Even the authors of one of these studies have now admitted publicly that the insurance companies actually asked them to do an incomplete job.
It’s smoke and mirrors. It’s bogus. And it’s all too familiar. Every time we get close to passing reform, the insurance companies produce these phony studies as a prescription and say, "Take one of these, and call us in a decade." Well, not this time.

Beyond slamming the most obvious target, Obama at the close broadened the scope and raised the stakes, framing the health reform bill as a test case for the functioning of American democracy:

Last November, the American people went to the polls in historic numbers and demanded change. They wanted a change in our policies; but they also sought a change in our politics: a politics that too often has fallen prey to the lobbyists and the special interests; that has fostered division and sustained the status quo. Passing health insurance reform is a great test of this proposition. Yes, it will make a profound and positive difference in the lives of the American people. But it also now represents something more: whether or not we as a nation are capable of tackling our toughest challenges, if we can serve the national interest despite the unrelenting efforts of the special interests; if we can still do big things in America.

I believe we can. I believe we will. And I urge every member of Congress to stand against the power plays and political ploys – and to stand up on behalf the American people who sent us to Washington to do their business.

Obama here is not only turning the spotlight on lobbyists just as they kick into high gear -- there's also a veiled threat to expose selected targets in Congress (Democrats, since there's no Republican votes except maybe Snowe's) who try to hold the final bill hostage to various giveaways.

It's been said by many that Obama needs to land a punch in a major domestic policy fight. Let's see specifically what he chooses to fight for as health care reform approaches the endgame.

Does the public option rest on a thin Reid?

2009-10-16T12:24:00.000-07:00

Pre-gaming the Harry Reid-led meetings to merge the Senate Finance Committee bill and the HELP bill, Ezra Klein highlights an important inflection point for the public option:

If Reid decides to put a public option, or some sort of public option compromise, into the bill, then it would require 60 senators to remove it on the floor, and only 41 senators to defend it. Conversely, if he decides to leave the public option fight for the floor, then it will take 60 senators to add it into the bill, and only 41 to block it. That means that groups who see an issue decided in their favor during the blend have a huge advantage over groups that are left to fight it out on the floor.

Of course, if Reid and his gang of 3-4 do include a public option (or some ghost of one) in the bill they bring to floor debate, and thus make it difficult to remove the public option on the floor, it will still ultimately take 60 senators to achieve cloture and bring any bill to a vote in the Senate.

Gov. Palin, 2006--2009?

2009-10-16T07:30:00.000-07:00

I'll leave it to Alaskans to shoot down the lies and distortions that doubtless pepper Sarah Palin's review of her record as governor in this deep foray into energy policy in NRO.

One representation, though, leaped out at a lower 48er:

— Sarah Palin was governor of Alaska from 2006 to 2009, and the Republican candidate for vice president in 2008.

2006-2009, eh? Sounds like three years, not 20 months. Wasn't Palin elected in 2006? Yes, but she took office on Dec. 4 -- so her tenure includes 27 days of that year. Sort of like a person who was born in 1899 and died in 2001 claiming a life spanning three centuries.

Would that all Palin's massagings of the truth stuck this close to the facts. Halcro, Mudflats et al, have at these sunny assertions:

The state’s government has made safeguarding resources a priority; when I was governor, for instance, we created a petroleum-systems-integrity office to monitor our oil and gas infrastructure for any potential environmental risks.

Over 20 percent of Alaska’s electricity currently comes from renewable sources, and as governor I put forward a long-term plan to increase that figure to 50 percent by 2025.

In Alaska, we’re developing the largest private-sector energy project in history — a 3,000-mile, $40 billion pipeline to transport hundreds of trillions of cubic feet of natural gas to markets across the United States.

For the Lord and for Gideon...

2009-10-15T05:39:00.000-07:00

Xpostfactoid was forced to tangle on the pages of the FT with our favorite columnist, Gideon Rachman, after one of his periodic bouts of Obamaskepticism. Deja vu...

Another respondent to Rachman has an interesting scope on the rope-a-dope trope.

Ah, the FT...our home away from home.

The Japanese sway to Obamameter

2009-10-14T18:18:00.000-07:00

The Times revisits the Japanese passion for Obama's speeches, which have become a staple of the country's multi-billion dollar English language instruction industry. While the CDs, books, etc. based on the speeches presumably break down the language, something nonverbal is at at work in their selling power:

But there are probably a large number of buyers who do not really possess the basic English skills to understand his speech, said Yuzo Yamamoto, an editor at Asahi Press. Since the sales took off, he has received postcards from readers saying they had been touched by Mr. Obama’s speeches, but “those same people have said they were moved even though they didn’t understand English well,” he said. “Some even said the only phrase they caught was, ‘Yes, we can.’ They said they were in tears nonetheless.”

Mr. Yamamoto said there was a sincerity about Mr. Obama’s speaking style that listeners could perceive phonetically, combined with a delivery that was almost musical.

I don't know what's more uncanny: Japanese enthusiasm or Obama's rhetorical power. I tried to capture some of its rhythmic and symbolic wellsprings the day after his election:

But Obama's speech is also "poetic" in a more primal sense, in its rhythms and pacing. Mostly it's a matter of strong repetition. The sentences are often long, with clause piled on clause. But those clauses are bound together by parallel structure -- most often by anaphora, the repetition of beginning words. There's really nothing fancy about it: anaphora is almost his only grammatical figure...A long Obama sentence is like a row of Doric columns. The mind follows without fatigue, buttressed by the graceful repetitive structure.

I am as susceptible myself as the customers in Utako Sakai's beauty parlor.

Bruce Bartlett, Keynsian?

2009-10-13T17:56:00.000-07:00

Bruce Bartlett, semi-repentant supply-sider and quasi neo-Keynsian, on one of many valuable taboos Republicans blew through:

Indeed, by destroying the balanced budget constraint, starve-the-beast theory actually opened the flood gates of spending. As I explained in a recent column, a key reason why deficits restrained spending in the past is because they led to politically unpopular tax increases. But if, as Republicans now maintain, taxes must never be increased at any time for any reason then there is never any political cost to raising spending and cutting taxes at the same time, as the Bush 43 administration and a Republican Congress did year after year.

This is by way of long intro to Barlett's new book, The New American Economy.

A mantra for true health care reform

2009-10-13T07:47:00.000-07:00

My takeaway from T.R. Reid's comparative look at national health care systems, The Healing of America, is distilled in this mantra from former British health minister John Reid:

We cover everybody, but not everything (p. 221).

That is the key to equitable, effective, sustainable health care delivery. As (T.R.) Reid's tour of successful health care systems makes clear, the very different systems at work in France, Germany and Japan (which channel payment through private but nonprofit insurers), Canada (single payer, Medicare model) and Britain (direct government funding) share these three elements:

1. Everybody has the same access to the same treatment
2. Every provider of each treatment (or of each patient, in a capitated system) gets the same pay as every other provider of that treatment.
3. One entity sets all treatment prices for the whole nation (or province, in Canada's case).

Establishing these conditions doesn't make cost control easy. It just makes it possible.

The health care reform bills pending in the U.S. won't create these conditions in one fell swoop. At best, they will establish adequate minimum insurance coverage standards and create viable nonprofit alternatives to the for-profit industry. Then, if we're lucky, those nonprofit options will indeed kill off for-profit insurance, exactly as AHIP fears.

AHIP Report: Disingenuous, but pushing toward broader coverage?

2009-10-12T19:21:00.000-07:00

Ezra Klein and Jonathan Cohn fisk a PricewaterhouseCoopers study commissioned by the America's Health Insurance Plans (AHIP) purporting to show that the Baucus bill will drive up insurance premiums by a) not putting enough teeth in the individual mandate to purchase insurance, b) imposing new taxes on insurers that will be passed through to customers, and c) driving "cost shifting" from cost-cutting public plans to private plans that will allegedly pick up the slack in payments to providers. Klein and Cohn point out that lower fees paid by public plans should drive the for-profit competition's prices down, not up; that excise taxes on expensive plans should push companies into cheaper plans; and that PwC conveniently omitted the bill's likely impact on buyers' behavior.

All that said, this AHIP response is interesting:

Karen Ignagni, head of America's Health Insurance Plans, the trade group that released the report, stood by its findings. The CBO estimated that the Finance bill would cover 94 percent of legal residents by 2019, but Ignagni said insurers prefer coverage levels in the "high 90s."

Well, so do I, and so do most House Democrats, including the leadership -- who, for that matter, also want to get rid of the excise tax that the AHIP-commissioned report takes aim at. The report may be disingenuous. But it's actually trying to push reform to the left to the extent that doing so means stimulating more spending on health care -- by individuals, the government and employers.

Of course, AHIP is dead-set against the public option, which is designed to drive premium costs down; the argument that it would have the opposite effect on private plans seems particularly disingenuous. Still, the net effect of the pressure effected by this 'research' could be to strengthen and accelerate the move toward universal coverage, through stricter individual mandates softened by more generous subsidies. If the insurers gain those points, and lose on the pubic option, the result could indeed by "coverage levels in the high 90s." Which is still a few points short of where they should be.

UPDATE: Ezra Klein nicely encapsulates AHIP's argument: they want more customers dragooned via a strong individual mandate, but also want to kill all the proposed taxes and cost control measures that make the mandate viable.

Commonwealth Club: 78,000 Americans die yearly for lack of "timely and effective" health care

2009-10-11T13:35:00.000-07:00

In a much-cited speech asserting the moral imperative for universal health insurance, Rep. Alan Grayson cited a Harvard study, published in the American Journal of Public Health, finding that just short of 45,000 Americans die prematurely every year for lack of health insurance.

A just-released state scorecard from the Commonwealth Club Commission on a High Performance Health System, scoring the relative effectiveness of each state's health care system, uses a somewhat different measure but comes up with an equally startling statistic: that if all states could reach the level of care achieved by top performing states,

Nearly 78,000 fewer adults and children would die prematurely every year from conditions that could have been prevented with timely and effective health care.

If this is true, more Americans die every year for want of "timely and effective" care than were killed in Vietnam or than die each year in car accidents. Moreover, even the "highest performing" state, Massachusetts, at the time of study ( when it had just begun to implement its universal health insurance plan) still left 7% of its adult working population uninsured -- and so significantly underperformed every industrialized nation in the world except the U.S. (The state with the highest percentage of working uninsured adults, at 32%, is Texas, where in the mid-90s Governor George W. Bush killed by neglect an attempt to establish a health insurance exchange for small businesses -- at least according to the exchange's chairman at the time of its demise).

The study also includes an incidental but striking congruity with CBO scoring of the Baucus bill. As noted, the study found that Massachusetts left 7% of its working adult population uninsured. Not surprisingly it concluded that if all states reached that level

Twenty-nine million more people would have health insurance - cutting the number of uninsured by more than half.

According to the CBO's estimate, the Baucus bill over ten years would cover 94% of legal U.S. residents and reduce the number of uninsured by...29 million. In other words, once fully implemented (by about 2014) it would achieve nationally the level of coverage that Massachusetts achieved in its first phase of implementation.

The Commonwealth Club report also includes some good news, most notably

that national efforts to measure, benchmark, and publicly report performance had a marked effect on quality improvements at the state level. Following a national effort to track and report hospital treatment data, nearly all states improved on measures of treatment for heart attack, heart failure, pneumonia, and prevention of surgical complications. In some instances, the lowest state rate now exceeds the average three years ago. In addition, most states improved significantly on several measures of the quality of care in nursing homes (reductions in pressure sores, pain, and use of restraints) following a national effort to make that data publicly available.

Those results suggest that measures in the Baucus bill to hold hospitals accountable for outcomes and infection rates could be effective and yield significant savings.

Health care endgame: lobbyist pressure vs. "deficit neutral" pledge

2009-10-11T05:50:00.000-07:00

Raising a front-page alarm, the Times' David Kirkpatrick warns that lobbyists are knocking the teeth out of all the significant cost control measures in pending health care legislation. This narrative cuts against the grain of the media attention focused on the CBO's verdict that the Baucus bill would reduce the deficit by $83 billion over ten years and by more in the second decade.

While the Baucus bill seems also to be the White House's template, Kirkpatrick usefully points out that it's only one of five bills making their way through House and Senate, and that under intense lobbyist pressure House Democrats have lined up against two central cost-cutting measures, the independent "MedPAC on steroid" commission (dear to Obama's heart) empowered to make regular recommendations for Medicare cost savings, and the excise tax on so-called "Cadillac" health care (expensive) plans that some employers offer to (mainly unionized) employees. Resistance to lobbyist pressure against the MedPAC proposal has been undercut by the Obama Adminstration's side deals with pharmaceuticals and hospitals to limit the amount that MedPAC could cut their payments -- now all other interest groups are clamoring either for equivalent carve-outs or to kill MedPAC altogether.

Negotiation between the House and Senate could cut two ways. The House wants a public option -- arguably the strongest cost controlling measure on the table, which allegedly lacks support in the Senate. The Senate, in turn, is more amenable to the Baucus cost controls opposed by Democrats in the House. One would like to think that the natural compromise would be "both/and" -- a public option and an excise tax and MedPAC. Alas, that would mean frustrating all the lobbying interests. On the other hand, there is genuine pressure for the bill to be scored as deficit neutral -- so a compromise can't cut out all cost control measures regarded as credible by the CBO. So the worst-case compromise -- no public option and no MedPAC or attempt to tax expensive benefit plans -- is likewise hard to imagine. Perhaps we'll end up with a weak excuse for a public option (or potential, to-be-triggered public option), a wholly or partially neutered MedPAC, and other tax substitutes for the excise. That would mean getting two thirds of the way toward universal coverage in five years while leaving serious cost control to another, still-more-desperate day.

In fact, T.R. Reid's survey of national health plans that work makes it pretty clear that there can be no significant health care cost control unless the government sets the rates for all procedures offered by all providers, either through a single payer system or through a tightly regulated, probably nonprofit, insurance industry. As long as health insurance is dominated by for-profit insurers with the freedom to set their own rates and coverage rules, the U.S. will continue to spend twice as much as other developed countries on health care. The only hope I see is either a strong public option or other nonprofit alternative slowly killing off the health insurance industry -- or else, continued inflation so out of control that universal desperation finally becomes strong enough to legislate the death of the industry.

It should be remembered that Obama is a long-range planner, committed by philosophy and inclination to effect change by "turning the battleship a few degrees" at a time. Bill Clinton confessed, while chronicling other achievements, "We bit off more than we could chew on health care." Obama, using Clinton as cautionary foil as much as George W. Bush did his father, decided from the start to enlist the health insurance industry rather than fight it head on. I hope and trust that he recognizes that the U.S. will never have an efficient, affordable health care delivery system as long as private for-profit insurers are free to operate as they do now -- with broad freedom to set coverage rules and repayment rates (in the current legislation, there will be some curbs on their freedom to set coverage rules, but probably not enough). Newt Gingrich's long-range plan for Medicare -- "first we're going to cut it off, then we're going to kill it" -- should define Obama's approach to the U.S. health insurance industry.

Pitch perfect as usual

2009-10-09T09:26:00.000-07:00

What else could Obama say about winning the Nobel just 37 weeks into his Presidency?

Mr. Obama said he doesn't view the award "as a recognition of my own accomplishments," but rather as a recognition of goals he has set for the U.S. and the world. Mr. Obama said, "I do not feel that I deserve to be in the company of so many transformative figures that have been honored by this prize."

But, he said, "I will accept this award as a call to action, a call for all nations to confront the challenges of the 21st century.''

Actually, the claim that Obama has so far accomplished nothing concrete on the world stage is exaggerated. Under his leadership, the G-20 meeting in March, at the depths of the financial crisis, exceeded expectations, producing a strong financial commitment to cushion the downturn for developing nations. The G-20 in late September also surpassed expectations, effectively establishing the G-20 as successor to the G-8 in real decision-making power and subjecting member nations to regulatory peer review. The meeting of the U.N. Security Council last month exceeded expectations, securing a commitment to revitalize and strengthen the Nuclear Nonproliferation Treaty. And the highest-level direct negotiation with Iran in 30 years exceeded expectations, yielding Iran's agreement to submit about 75% of its known nuclear stockpile to Russia for enrichment and to open its newly disclosed nuclear facility outside Qom to inspection.

Of the G-20 meeting in March, Philip Stephens wrote, "Mr Obama shows wisdom beyond his years in realising that to understand the extent of US power – and it is still unrivalled – a president must also map its limits" That's true of all four of the meetings referenced above. That's why each yielded something concrete.

Not the stuff of a Nobel by established standards, perhaps. But Obama has done far more than deliver a handful of uplifting speeches on the world stage. Though those speeches themselves were a key part of the paradigm shift that Stephens articulated.

Brooks v. Brooks on the Baucus bill

2009-10-09T05:13:00.000-07:00

David Brooks continues to write nonsense about health care.

Professing ambivalence about the Baucus bill, he complains in one breath that it "will retard innovation by using monopoly power to squeeze costs." Two paragraphs later, lauding the bill's "many provisions to make government-run health care more rational," he includes that it "would create a commission to perpetually squeeze costs," also cataloging specific measures favored by health care experts -- bundling payments, encouraging doctors to work in teams, improving IT, measuring comparative effectiveness. He acknowledges that savings from these measures "could be significant."

As for that free market shibboleth that cost controls are always bad: in health care, virtually every industrialized nation has found them necessary. Is Brooks aware that in France, Germany and Japan, three countries that get better health outcomes than the U.S. at half to two-thirds the cost, the central government sets prices for every medical procedure performed in the country, and all insurers are required to pay all bills submitted under that schedule by all providers? That those countries provide universal comprehensive coverage at minimal cost to their citizens? That the fee schedules are completely transparent, posted on doctor's office walls in France, available in a phone book-sized reference in Japan? (For a doctor's- and patient's eye view of these systems, see T.R. Reid's The Healing of America.)

The only "innovation" squeezed by governmental cost controls is the innovation of insurers, ingeniously determining how not to cover procedures or how to wring out maximum premiums by charging different rates for different levels of coverage.

Yes, health care providers in all three countries feel squeezed by government cost controls. Yes, they make much less than doctors in the U.S. They also come out of medical school with zero debt, pay pennies by US standards for malpractice insurance, and spend almost no time or money on administrative costs -- in contrast to American doctors, who have to employ whole staffs to deal with the byzantine billing and claims approval processes of multiple insurers.

Brooks also claims that the Baucus bill (or any set of subsidy levels for people purchasing insurance on exchanges) "will impose huge costs on people as they rise up the income ladder, distorting the whole economy."

Subsidies keyed to income are only relevant to those who do not get insurance from their employer, including the self-employed. Right now, such people suffer "huge costs" indeed -- buying individual insurance on the open market with no subsidy. For many, a rising income will be the result of better employment, which likely means employer-provided health care. For the self-employed or those who work long-term in workplaces that don't provide insurance, it seems perverse to complain that reducing subsidies as their income increases is an imposition of "huge costs."

T.R. Reid: For-Profit Insurance Destroys Health Care Delivery

2009-10-08T06:21:00.000-07:00

T.R. Reid's indispensable book about successful national health systems, The Healing of America, provides a patient's- and doctor's-eye view of health care delivery in France, Germany, Japan and other countries that provide complete coverage for all residents and pay half to two thirds of what the U.S. pays for health care (as a percent of GDP) with better outcomes. The book induces startling clarity about the key dysfunctions of our system.

Our primary dysfunction is simple. While France, Germany and Japan all rely on private insurance to pay for comprehensive health care, the private insurers are all nonprofit. In all three countries, the government sets uniform rates for all procedures; all providers charge the same rates, and all insurers must pay all claims. In France, every citizen's complete medical history, including procedures performed and their costs, are embedded in a national health card (the carte vitale). Doctors simply record each service performed - and get paid by one of the country's fourteen insurers within a week.

The lesson is clear: U.S-style for-profit insurance for basic comprehensive health care is purely parasitical (for-profits are in the mix in The Netherlands, but they're subject to strict price controls and risk equalization, by which plans with a higher concentration of sick members are paid more). Our for-profit health insurance industry creates a needless bureaucracy, matched in no other country, which it pays itself handsomely to manage, and it makes money by denying claims.

Any reform that makes health insurance available and affordable to all Americans is worth doing. Mandates requiring insurers to cover all eligible comers without differentiating cost according to condition are key; so are mandates laying out minimum coverage standards.

But to meaningfully narrow the gap between health care costs in the U.S. and other rich countries, reform would have to kill for-profit insurance, quickly or slowly. Health care co-ops are actually closer to the system that works so well in France and Germany than a single "public option." But in those countries, the "sickness funds" did not have to evolve in competition with for-profits.

Every industrialized country is wrestling with rising health care costs. In France, the sickness funds operate at a deficit; in Germany, doctors are up in arms because the government keeps imposing new limits on permissible treatments for given conditions. But both countries are continuing to reform from a position way ahead of us, with complete universal coverage, costs 1/2--2/3 of ours, and the government in complete control of rates and mandated coverage.

None of this should be secret. Legions of American health care experts know how things work in Europe and Japan. Senators are reading Reid's book. But as Reid stresses, it's political anathema in the US to suggest cribbing from other countries' successes. Our national 'debate' is obfuscated by lack of full discussion of how successful systems work.

Future Perfect on health care reform

2009-10-07T12:24:00.000-07:00

Eyes on the prize: I have little doubt that Kevin Drum is right about this:

Healthcare reform might be controversial right now, but if Obama gets a bill onto his desk and signs it, it will become a huge triumph almost overnight. Support for both the bill and for Obama will rise steadily, and Democrats of all kinds will reap the benefit of being seen as tough enough and savvy enough to get it passed. This is the fundamental reason that I'm optimistic about healthcare reform.

Popular approval may have a "donut hole": there may be bumps in perception, even over years, in a rocky implementation. And assuming that the final product is weaker in several particulars than it should be, a key question is whether it creates a scaffold that can be built on : fair requirements for minimum coverage in health plans, controls against insurer cherry-picking to protect the exchanges, MedPAC or some near equivalent to keep the ball moving on cost control initiatives. But assuming the final legislation is not wired for failure -- like, say, the Texas Insurance Purchasing Alliance of the mid-nineties -- then Drum's "future perfect" should be on target.

Health care coverage continues to melt down

2009-10-07T08:50:00.000-07:00

While Republicans scream about Democratic efforts to trim Medicare costs, working Americans' coverage continues to dissolve. Insurance Journal reports:

Aon Consulting, which surveyed 1,313 employers nationwide, found that 70 percent are planning to increase employee contributions and 67 percent are expecting to raise deductibles, co-pays, coinsurance or out-of-pocket maximums.

Add a bit of cold comfort:

In addition, more than half of employers are expecting to introduce or expand a wellness program next year, and 34 percent are planning to introduce or increase financial incentives for wellness programs in 2010.

Even more effective for employers than boosting employee payouts is trimming the rolls of the insured:

Employers have been implementing various types of audits as a short-term savings solution and the survey says more will follow suit. The survey found that 46 percent of organizations conducted a dependent eligibility verification audit in 2009 or earlier, and 20 percent are planning to do so in 2010 or later. These audits are designed to save on health care costs by ensuring only eligible dependents are covered.
"Employers who conduct dependent eligibility audits can see immediate savings ranging from 3 percent to 10 percent in dependent health care costs," said Tom Lerche, U.S. Health Care Practice Leader with Aon Consulting.

I wonder whether these roster trimmings fall disproportionately on gay couples?

Vengeance PR from the Pentagon?

2009-10-06T08:23:00.000-07:00

I understand that the new strategy in Afghanistan emphasizes protecting and winning over the civilian population. You would think that metrics such as body counts would raise Vietnam ghostss. But in the wake of a week in which ten U.S. soldiers died, this latest from the Pentagon (as reported by the AP) seems to answer a visceral need:

KABUL, Afghanistan — Afghan and American forces killed 40 militants in 24 hours as they hunted in mountainous eastern Afghanistan for insurgents behind one of the deadliest attacks of the war for U.S. troops, the defense ministry said Tuesday.
Ministry spokesman Gen. Mohammad Zahir Azimi said 10 Afghan army troops were also killed in the same period around the country, most of them in Nuristan province's Kamdesh district, where eight Americans and two Afghan security troopers died Saturday after hundreds of Taliban militants overwhelmed their remote and thinly manned outposts.

David Brooks' lazy free market fantasy

2009-10-06T05:17:00.000-07:00

Before publishing a disingenuous parable setting up false categories of free-market versus activist government reform, David Brooks should have had a chance to read a cautionary tale of failed health care reform that appeared on the very same Times op-ed page as his own column.

Brooks spins out the reform approaches of "Mr. Bentham" (Obama Democrat) and "Mr. Hume" (free market conservative, vaguely reminiscent of Bush). Presumably these are avatars of nineteenth century reformer Jeremy Bentham and philosopher David Hume, though the affiliations are too tenuous to be worth parsing.

Mr. Bentham is a type AAA superwonk with a solution to everything; Mr. Hume is a lazy skeptic who recognizes his limitations. While Brooks takes a few swipes at "Hume," his sympathies clearly rest with him.

Mr. Bentham comes up with the Baucus bill for health care reform and the Waxman-Markey energy bill; Mr. Hume proposes in both cases to let the market work its magic. Here he is on health care:

“Why don’t we just set up insurance exchanges with, say, 12 different competing policies? We’ll let everybody choose a policy, and we’ll let people keep any money they save. That way they can set off a decentralized cascade of reform, instead of putting all the responsibility on us here.”

Yeah, why don't we just. It's really easy to estblish robust competition benefiting consumers among for-profit health insurers, and every market has twelve competitors ripe for recruitment. That's where column B, an op-ed by the former chairman of the Texas Insurance Purchasing Alliance, Cappy McGarr, offers an appropos reality check.

McGarr chronicles the failure of Texas' effort in the early nineties to establish a health insurance exchange for small businesses--a failure he blames largely on neglect from Governor George W. Bush (the quasi-model, ironically, for Brooks' "Mr. Hume," with imagery borrowed from Maureen Dowd's Boy King columns). The exchange died, according to McGarr, for want of either a public option or strict rules to prevent insurers from cherry-picking small corporate customers outside the exchange:

Most important, though, our exchange failed not because it wasn’t needed, and not because the concept wasn’t sound, but because it never attained a large enough market share to exert significant clout in the Texas insurance market. Private insurance companies, which could offer small-business policies both inside and outside the exchange, cherry-picked relentlessly, signing up all the small businesses with generally healthy employees and offloading the bad risks — companies with older or sicker employees — onto the exchange. For the insurance companies, this made business sense. But as a result, our exchange was overwhelmed with people who had high health care costs, and too few healthy people to share the risk. The premiums we offered rose significantly. Insurance on the exchange was no longer a bargain, and employers began backing away. Insurance companies, too, began leaving the alliance.

The Texas exchange failed, in other words, for want of the very types of provisions that Brooks lampoons in the Baucus bill: "He’d design a set of insurance policy regulations to make sure everybody gets uniform care"( along with various crucial experimental measures to restrict overtreatment and overbilling that Brooks does not criticize in detail).

Brooks recognizes on some level that free market fundamentalism has failed. His Mr. Hume "never could very accurately predict how the market was going to move." But he holds reflexively to his contempt for good-faith efforts to create market conditions in which health insurance competition can flourish. He won't recognize, as Paul Starr has shown, that the Baucus bill -- and indeed, all the Democratic health care bills pending in both chambers -- are comprised entirely of ideas proposed by Republicans over the past four decades. He won't consider, with Jonathan Cohn, whether an exchange minus a public option might work with strict regulation of private insurers. He hasn't engaged the tough questions driving the debate -- for example, whether the Wyden amendment opening the exchanges to all employees might foster real competition, or whether co-ops might work, or how to bend the cost curve if he doesn't like the efforts to do so that he implicitly lampoons in the Baucus bill. He prefers, with his own Mr. Hume, to whine and fantasize easy answers.

Self-funded employers against the public option

2009-10-04T07:43:00.000-07:00

Last week, Matt Miller expressed incredulity that the major business lobbies would help shoot down the Wyden Free Choice Amendment to the Baucus bill, which would enable all employees to opt out of their employer's health care plan and buy insurance on the insurance exchanges that the various health care reform bills will establish for the uninsured. Miller forecast:

Big business thinks that giving employees this choice would be a calamity. To which one can only ask: Have these business lobbies lost their minds?

When the post-mortems on the health-care reform debate are written, the biggest mystery will be why big business fought so hard to stay in the health-care business even as soaring health costs surpassed corporate profits and diverted executive time better devoted to actually running companies.

Excellent question. Miller can only speculate that corporate human resources chiefs have sold their companies a bill of goods. And that seems to be the case on another health care reform front: employers apparently also don't want their self-funded plans to be subject to competition from a public option, i.e. a government-administered plan offered on the new insurance exchanges.

More than half of Americans who get their health coverage through their employers work for companies that self-fund their own health plans, usually hiring an outside company to administer the plan. The organization representing such plans and the companies servicing them, the Self Insurance Institute of America, is dead-set against the public option, apparently fearing it would trigger a stampede out of employer-funded plans.

Why? As reported by Matt Brodsky of Risk & Insurance, Cliff Roberti, chief lobbyist for the group, recently issued a warning at the group's annual meeting:

Not to be "overly dramatic," said Roberti, addressing an audience of SIIA members, but if healthcare reform take a partisan turn (meaning the passage of government-run insurance plans), a lot of people at the conference could be in another business in two years.

Who might lose their jobs if employees stampeded out of employers' health plans? SIIA members include company executives who oversee self-funded plans (as well as at captive insurance companies, generally used for property/casualty insurance); Third Party Administrators (TPAs), the entities that run these plans, which include both subsidiaries of major health insurers and stand-alone companies specializing in this service; and stop-loss insurers, which offer coverage for big losses to self-funded plans. The SIIA website defines its constituency as follows:

If your company is a self-insured employer, group fund (SIF), third party administrator, stop-loss/excess insurance carrier or provider network, SIIA' s government relations services are a tremendous membership benefit.

Are corporate America's interests really aligned with those of TPAs and stop-loss insurers? Is corporate policy on this front really driven by HR executives, as Matt Miler suggests? Why is the prospect of reduced employer responsibility for employees' health care so threatening to employers?

Change you can believe in? By degrees...

2009-10-03T03:46:00.000-07:00

Many who responded to Obama's promise of change, myself sometimes among them, are disturbed by his willingness to trim back major initiatives. A stimulus that's one third tax cuts, with aid to states and municipalities cut back. Health care reform without a public option. Financial regulatory reform that leaves "too big to fail" banks intact. An end to torture with a continued policy of preventive detention.

Against those frustrations, set Charles M. Blow's explanation for a marked uptick in conservative sentiment among the electorate:

The Obama administration’s response to the financial and automotive crises and its pursuit of a wide range of reforms is the epitome of new and untried. Major change has come much too quickly for far too many. The response: retreat to a cocoon of conservatism.

And recall Frederick Douglass's assessment of Lincoln:

Viewed from the genuine abolition ground, Mr. Lincoln seemed tardy, cold, dull, and indifferent; but measuring him by the sentiment of his country, a sentiment he was bound as a statesman to consult, he was swift, zealous, radical, and determined.

Obama won by raising hopes that he would "bend the arc of history" and specifically reverse this country's hard swing to the right over the past forty years. But he's spoken of that arc (in effect) mathematically, envisioning fundamental change as moving a battleship a few degrees. Let's see how things look when we've moved a ways around the bend.

Taliban verdict: George Bush let us back in

2009-10-02T09:29:00.000-07:00

Newsweek has an incredible oral history of the Taliban resurgence -- six first-person narratives from current-day Taliban tracking their experience from the American overthrow to the present. It's excrutiating to follow their progress from the despair of 2002, when they never dreamed there would be a viable Taliban resurgence, to the present, in which they all brim with the confidence of the North Vietnamese that they can outlast the foreign invader.

The most politically sophisticated of the six, Maulvi Mohammad Haqqani, a former Taliban deputy minister and now a recruiter and propagandist, perhaps quite consciously verifies the dominant strategic rap against George , W. Bush. Here's his account of a pivotal period:

HAQQANI:Arab and Iraqi mujahedin began visiting us, transferring the latest IED technology and suicide-bomber tactics they had learned in the Iraqi resistance during combat with U.S. forces. The American invasion of Iraq was very positive for us. It distracted the United States from Afghanistan. Until 2004 or so, we were using traditional means of fighting like we used against the Soviets—AK-47s and RPGs. But then our resistance became more lethal, with new weapons and techniques: bigger and better IEDs for roadside bombings, and suicide attacks.

It's impossible to read these accounts without getting the sense that what may be prohibitively difficult now -- fostering a viable non-theocratic Afghan government -- may have been quite achievable in 2002-2003. The six jihadis chronicle a shift in Afghan attitudes toward the government and the insurgents - driven by errors of an undermanned U.S. force that had not yet been "Petraeusized" and an Afghan government that was corrupt and ineffectual from the start:

MOHAMMAD:Those first groups crossing the border were almost totally sponsored, organized, and led by Arab mujahedin. The Afghan Taliban were weak and disorganized. But slowly the situation began to change. American operations that harassed villagers, bombings that killed civilians, and Karzai's corrupt police and officials were alienating villagers and turning them in our favor. Soon we didn't have to hide so much on our raids. We came openly. When they saw us, villagers started preparing green tea and food for us. The tables were turning. Karzai's police and officials mostly hid in their district compounds like prisoners.
YOUNAS: After these first few attacks, God seems to have opened channels of money for us. I was told money was flowing from the Gulf to the Arabs.
Our real jihad was beginning by the start of 2005. Jalaluddin Haqqani's tribal fighters came actively back to our side because the Americans and the Pakistanis had arrested his brother and other relatives. He appointed his son Sirajuddin to lead the resistance. That was a real turning point. Until then villagers in Paktia, Paktika, and Khost thought the Taliban was defeated and finished. They had started joining the militias formed by the Americans and local warlords, and were informing on us and working against us. But with the support of Haqqani's men we began capturing, judging, and beheading some of those Afghans who worked with the Americans and Karzai. Terrorized, their families and relatives left the villages and moved to the towns, even to Kabul. Our control was slowly being restored.

That flow of money from the Gulf to the Taliban is a bitter historic replay of an earlier flow -- from U.S. coffers to the Mujihadeen fighting the Soviets and Soviet-backed Afghan government in the 1980s.

Haqqani, the propagandist also may be trying to get his two cents in to the Obama Administration's very public current strategic review:

Personally I think all this talk about Al Qaeda being strong is U.S. propaganda. As far as I know, Al Qaeda is weak, and they are few in numbers. Now that we control large amounts of territory, we should have a strict code of conduct for any foreigners working with us. We can no longer allow these camels to roam freely without bridles and control.

Newsweek closes the six interwoven narratives with this parting irony:

AKHUNDZADA: Sometimes I think what's happened is like a dream. I thought my beard would be white by the time I saw what I am seeing now, but my beard is still black, and we get stronger every day.

David Brooks lambastes Democrats for agreeing with him

2009-10-02T04:59:00.000-07:00

Never one for logical rigor, David Brooks ignores himself to a breathtaking degree in today's column.

He begins with an intriguing hypothesis: our latter day Father Coughlins -- Rush Limbaugh, Glenn Beck, Sean Hannity & co. -- command plenty of attention but virtually no votes. His evidence is probably selective, but it's an intriguing hypothesis. They are puffed up by enablers. True enough. But...

They are enabled by cynical Democrats, who love to claim that Rush Limbaugh controls the G.O.P.

Just another politically expedient lie, right? Oh, wait --

And the saddest thing is that even Republican politicians come to believe it [that the shock jocks have real power]. They mistake media for reality. They pre-emptively surrender to armies that don’t exist.
They pay more attention to Rush’s imaginary millions than to the real voters down the street. The Republican Party is unpopular because it’s more interested in pleasing Rush’s ghosts than actual people. The party is leaderless right now because nobody has the guts to step outside the rigid parameters enforced by the radio jocks and create a new party identity. The party is losing because it has adopted a radio entertainer’s niche-building strategy, while abandoning the politician’s coalition-building strategy.
The rise of Beck, Hannity, Bill O’Reilly and the rest has correlated almost perfectly with the decline of the G.O.P. But it’s not because the talk jocks have real power. It’s because they have illusory power, because Republicans hear the media mythology and fall for it every time.

To anyone who believes that democracy can't function without viable choices, it was a sad and shocking spectacle to witness a parade of Republican leaders first calling out and then kow-towing to Rush Limbaugh earlier this year. Democrats would rather have an opposition they can work with; as Paul Starr demonstrated recently, their health care bills are comprised almost entirely of Republican ideas past, but there's no one on the other side negotiating in good faith.

But in David Brooks' still partisan mind, Democrats who agree with him that the Republican party is entirely in the grip of media demagogues are "cynical." And what is Brooks? Pure-minded?

Attention, Clive Crook: "uncertainty" is an antidote to "unintended consequences"

2009-10-01T07:35:00.000-07:00

Clive Crook objects to the "uncertainty" that the public option injects into the health care reform debate. He also warns against unintended consequences. What he fails to recognize is that an element of uncertainty -- an "option" that may evolve in more than one direction -- is a way of coping with unintended consequences.

Below, Crook gets his "if...then" exactly backwards:

Democrats have been debating whether a "strong" public option should pay Medicare reimbursement rates, something an ordinary competitor could not do. If it did, this would drive down costs and have many other (not necessarily intended) consequences. It would be a big step towards Medicare for all. As I have argued before, there are worse things than Medicare for all, including in my view the present system. But this outcome is one of the things that the administration is saying it does not want. If you want Medicare for all, do what some Democrats do and make the case. If you don't, stop proposing a public option that would push the system towards it.
Politically, the problem with the public option is that it has added to the uncertainty, and hence the anxiety, that surrounds this reform. People want to know where all this is heading. The public option might be nothing, or it might be everything, depending on how it is done. But when advocates like Dionne say that it can be both everything and nothing at the same time, according to your preferences, then centrist voters are right to say, "No thanks."

Possible outcomes to creating a public option might be sorted into three categories: a) it has no great effect, becoming one health care 'option' for a limited percentage of the population; 2) it coexists in robust competition with private health care plans, as (to cite Obama's analogy) public universities do with private ones; or c) it proves a superior choice and causes private insurance to wither on the vine.

None of these outcomes is undesirable, unless a) transpires because the public option is neutered from the start and hence is never a viable option. Instituting a public option should either make private insurance better or prove it to be parasitical. It's a way of creating competition, not a prejudgment of the competitive outcome. "Uncertainty" is good. It's a condition of competition.

As for those lawmakers who would prefer "Medicare for all," i.e. a Canadian system, the public option is a rational -- not disingenuous -- way to get there. There's no virtue in ignoring political reality by pushing for a single payer system in the U.S. now. If the public option gets us there, it will do so in a prudent, incremental way, by earning its stripes as the best service offered. If the public option is a Trojan Horse, it's got to be one that runs, i.e., defeats the competition. If paying Medicare rates hurts quality, private plans ought to be able to differentiate themselves by paying higher rates, thereby presumably attracting better doctors.

Obama likes mechanisms that set the conditions for incremental, adjust-as-you-go change. That's how he's cast "MedPAC on steroids." A robust public option should be in that category.

If you read one post on health care reform...

2009-09-30T10:04:00.000-07:00

let it be Paul Starr's brief history, showing the extent to which the Dems' bills have incorporated Republican ideas floated over the past half century:

...the Democratic proposals are built around the ideas that Republicans used to favor -- those proposals already are bipartisan compromises. Unfortunately, they are compromises with a Republican Party that no longer exists.

This fundamental truth is not only sad but dangerous. It's no particular compliment to the Democrats to note that this country currently has only one viable political party. The Republican Party is right now neither fringe nor mainstream. It's in some volatile liminal zone between the two, a nativist, militarist, authoritarian, Social Darwinian dreamland.

Dispelling dystopian dyspepsia

2009-09-28T19:11:00.000-07:00

Gideon Rachman goes dystopian on us with a forecast of international failure on the Iranian front backlit with back-to-the-future foreboding of a new era of blood and iron. In a comment, I try to clear the air via Gary Sick and Roger Cohen's congruent glimpses of a route to a negotiated solution with Iran.

How to call out a President

2009-09-27T14:25:00.000-07:00

The blog Letters of Note posts a 1958 letter from Jackie Robinson to President Eisenhower, calling him out for suggesting for the umpteenth time that negroes be "patient" in the face of discrimination and oppression (h/t Andrew Sullivan).

Whose impulsive reaction to a President's speech does the letter's opening call to mind -- by way of contrast?

My dear Mr. President:

I was sitting in the audience at the Summit Meeting of Negro Leaders yesterday when you said we must have patience. On hearing you say this, I felt like standing up and saying, "Oh no! Not again."

No, Jackie Robinson, who broke baseball's color barrier by dint of superhuman self-restraint, did not leap up on the spot to impugn the President's honor. After the fact, "respectfully," he simply made clear in no uncertain terms (dangling modifier notwithstanding) the pusillanimity, hypocrisy, disingenuity and untenability of Eisenhower's patronizing position:

As the chief executive of our nation, I respectfully suggest that you unwittingly crush the spirit of freedom in Negroes by constantly urging forbrearance and give hope to those pro-segregation leaders like Governor Faubus who would take from us even those freedoms we now enjoy. Your own experience with Governor Faubus is proof enough that forbearance and not eventual integration is the goal that the pro-segregation leaders seek.

How generous that "unwittingly." How incontrovertible the logic. Here's to you, Mr. Robinson.

C.S. Lewis on Matt Latimer

2009-09-27T06:40:00.000-07:00

Love or hate his theology or his cultural preferences and prejudices, C.S. Lewis remains worth reading because of his imaginative grasp of human motive. Among the "multiple intelligences" classified by Howard Gardner he had in spades the type that observes its own internal working and extrapolates from self knowledge to psychological and sometimes sociological. Lewis was especially (you might say viscerally, personally) insightful about what he archaically deemed the temptations of 'the world'--the lust to be part of an 'inner ring,' to cede one's moral judgment for a place in the councils of power.

He was particularly scathing about the type of person who's often best adapted to penetrate such circles. This persistent type in his writings came to mind as I read an excerpt and various snippets of the newly published memoir of Bush speechwriter Matt Latimer. Latimer seems to cast himself as the sort tempted into but standing apart from an "inner ring" of ethically and intellectually bankrupt power players -- a disillusioned idealist. But his sneering, trash-heaping tone reminds me of that type itself. Here's a Lewis description from Out of the Silent Planet, of a character who ripens into a primary protagonist of evil:

Devine had learned just half a term earlier than anyone else that kind of humour which consists in a perpetual parody of the sentimental or idealistic cliches of one's elders. For a few weeks his references to the Dear Old Place and to Playing the Game, to the White Man's Burden and a Straight Bat, had swept everyone, Ransom included, off their feet. But before he left Wedenshaw Ransom had already begun to find Devine a bore, and at Cambridge he had avoided him, wondering from afar how anyone so flashy and, as it were, ready-made, could be so successful.

Compare Latimer:

Ed said the president wanted to see us in the Oval Office. The president looked relaxed and was sitting behind the Resolute desk. He felt he’d made the major decision that everyone had been asking for. That always seemed to relax him. He liked being decisive. Excuse me, boldly decisive. The president seemed to be thinking of his memoirs. “This might go in as a big decision,” he mused.

“Definitely, Mr. President,” someone else observed. “This is a large decision."

And:

At one point, during another of our marathon speechwriting sessions, Steve Hadley and Fred Fielding, the White House counsel, let us know that the president needed an FDR line—like “We have nothing to fear but fear itself.” The president had his own suggestion for such a line, however: “Anxiety can feed anxiety.” So we produced a speech with no real information and our FDR knockoff line. Here were some of the kinder reviews: “lackluster”; “there is no news here”; “the president should go away for a while.” The stock market dipped further.

And:

As Treasury started to use the bailout funds to invest directly in financial institutions, Ed wanted to come up with a name for the plan that made it sound better to the public, particularly conservatives who thought this was nothing more than warmed-over socialism. Yes, a catchphrase would solve everything. As we were working on this, Ed called a few of the writers on speakerphone with the idea he’d come up with: the Imperative Investment Intervention. “Oh, that sounds good,” one of us remarked, as the rest of us tried not to laugh. We decided that if a catchphrase must be deployed, surely we could come up with something better than a tongue twister with the acronym III. We started out with dark humor: the “I Can’t Believe It’s Not Capitalism” Plan; the MARX Plan. I suggested that we also apologize to the former Soviet Union and retroactively concede the Cold War.

This is not to suggest that Latimer's characterizations of chaos, off-the-cuff policymaking and cavalier message-crafting in the Bush administration is not accurate in many or even most particulars. But someone who trashes in humiliating detail the majority of colleagues he portrays in an account of 22 months of ultra high stakes work is not what I would call a a reliable narrator -- however emotionally gratifying his judgments may be to outraged progressives, disillusioned conservatives, aggrieved insiders, and other constituencies who recognize the Bush presidency as a disaster.

We are all boiling frogs

2009-09-24T15:49:00.000-07:00

James Fallows objects noisily to the ubiquitous metaphor of the frog that boils to death in a pot of water when the heat is turned up gradually; he calls for alternatives. Andrew Sullivan seconds. Many submissions have to do with smell or noise to which we grow acclimated, and some with gradually increasing one's capacity for pain or discomfort or with gradually deteriorating capacities.

None of these quite wash. What gives the boiling frog metaphor its bite (and it's a good metaphor - that's how it got to be a cliche) is that the frog ends up dead. Unfortunately, the best analogues may be the things that really kill us: clogging arteries, growing cancers. In fact the boiling water is mortality. Every year is a degree.

Battle of the Bush surrogates: Burt trumps Bolton in WSJ

2009-09-24T11:24:00.000-07:00

I like this quote selection by the WSJ's Jonathan Weisman, covering the U.N. Security Counsel's unanimous passage of "a nuclear-safeguards resolution drafted by the Obama administration to lay the legal framework for military and diplomatic action against nations that use civilian nuclear technology for military purposes." It captures the whole difference in worldview between the administrations of Bush Sr. and W.

First, John Bolton, Bush Jr.'s never-confirmed "ambassador" to the U.N., fulminates:

It's passing a resolution that doesn't have any impact on the real world that undercuts the credibility of the Security Council.

Next, Richard Burt, arms-control negotiator for Bush Sr., now with arms control group Global Zero. Burt

said similar proposals were put forward by the administration of George W. Bush. But they went nowhere.
"What the administration is trying to do is lay the groundwork for proposals that are formally adopted at the NPT conference next year," he said. "The administration views all this as part of the process of establishing a real international consensus against proliferation."

End of article. Way to frame it, Weisman.

Swallowing the fly in Afghanistan

2009-09-24T06:58:00.000-07:00

A moment of illumination in George Packer's profile (subscription required for whole) of Richard Holbrooke and the conundrum he's trying to manage in "AfPak":

James Dobbins, now with the RAND Corporation, couches the problem this way: "There is a gap between the reason we're there and what we're doing. The rational is counterterrorism. the strategy is counter-insurgency."

I'm reminded of the old song:

She swallowed the cat, to catch the bird,
She swallowed the bird to catch the spider...,
She swallowed the spider to catch the fly...

The problem is that the "fly" does need to be swallowed, and there may be no viable direct path, in an environment that breeds flies.

Then too, this conundrum is really always true of counterinsurgency, or rather of an outside power's support/control of a counterinsurgency. You're not there out of benevolence, but to check the empowerment of a force you perceive as malign and a threat to your own security.

DeLay of de land in Congress

2009-09-24T04:57:00.000-07:00

Tom DeLay may be a mean, corrupt extremist thug whose chief mission while in power was to sell sell legislation to lobbyists. But that doesn't mean he doesn't know the legislative process:

"The Democrats will do exactly what we always did, rewrite the bill over and over until they give all the members what they need to get to 218 votes. The Senate will do the same thing." It will, he predicts, be a straight party-line vote, and "maybe a few Republicans voting for it, but not many."

Right on cue, the Times today reports that Senator Bill Nelson, Democrat of Florida, is getting hammered by seniors up in arms about planned cuts in subsidies to Medicare Advantage providers, and is in turn holding out to have those cuts eliminated or scaled back. The Times' Robert Pear notes the likely effect if Nelson succeeds:

Approval of the amendment could invite other Democrats to ask for similar deals that might make the bill more palatable to their constituents, but more costly as well.

So we'll see what happens to all those lovely cost-saving measures in the Baucus bill that led the CBO to score it better than deficit-neutral.

The Times article also highlights the many channels of corporate influence. Nelson has received substantial contributions from the insurance industry, health professionals and pharmaceuticals -- a total of over $1.6 million, putting him at about #14 among Democratic senators. But he's being pressured also by seniors in Medicare Advantage programs (remember, he represents Florida), put up to it by their insurers (e.g., Humana), who are scaring them with letters that the Obama administrations calls "misleading and confusing." Ah, democracy...

As a footnote, one under-reported element of the health care debate is the performance and value (or lack thereof) offered by Medicare Advantage programs. The subsidies paid to Advantage providers have been targeted and denounced. Some programs have been flagged for misleading representations of benefits. Obama has implied that Advantage programs provide nothing of substance that seniors can't get from traditional, fee-for-service Medicare. At the same time, the programs should at least have the potential to implement many of the cost-saving measures touted by the Administration - global payment systems, preventive and wellness care, teams of doctors that communicate with each other. I'm going to see what I can scare up on the topic.

Is Obama trying to force a unity government in Afghanistan?

2009-09-22T18:56:00.000-07:00

On Sunday night, I noted that in his Sunday talk show blitz Obama seemed to offer a new rationale -- or a new emphasis in that rationale, at least -- for why he ordered fresh troops to Afghanistan in March:

I did order 21,000 additional troops there to make sure that we could secure the election, because I thought that was important. That was before the review was completed. I also said after the election I want to do another review (my emphasis).

Is Obama hesitating at the brink of escalation, holding back General McChrystal's report and request for additional troops, because the Afghan election was such a balls-up? Note that Obama not only tied his March decision to securing the election but implied that the subsequent review would be focused in large part on the election results.

Could the pause be an act of brinkmanship against Karzai? Will there be a sequence in which an Afghan unity government is announced, and then the administration announces a troop increase? Or is Obama simply preparing to cut bait?

Three legs of financial reform

2009-09-21T13:58:00.000-07:00

Today, two columnists tout two pillars of bank reform, each worrying that fearsome bank lobbying will bend the Obama administration's resolve.

In this corner, Clive Crook urges the G20 to follow Geithner's proposals and act in concert -- so that banks cannot forum shop -- in raising capital ratio requirements and a cap on total leverage for systemically important banks:

The global finance industry is in no position, yet, to mount a vigorous campaign against changes which, if they are adequate, will implicitly tax its growth. That is what higher capital requirements would do, and is precisely why they are needed. Checking the industry’s expansion must be seen as an aim of policy, not an unintended consequence.

And over at the New York Times, Paul Krugman insists that the sine qua non of true bank reform is compensation reform (as proposed back in January 2008 by Raghuram Rajan) -- retooling the current massive incentives for bankers and traders to take excessive risks :

According to recent reports, the Fed’s board is considering imposing new rules on financial-firm compensation, requiring that banks “claw back” bonuses in the face of losses and link pay to long-term rather than short-term performance. The Fed argues that it has the authority to do this as part of its general mandate to oversee banks’ soundness.

I wonder whether a third leg of the stool -- Obama's proposed banking consumer protection agency -- may not be the most important of all. No one seems to be paying much attention to this -- except the banks, which are vociferously opposed. Krugman nods toward this proposal, but also dismisses it as only "the beginning of reform."

Hmm. Notwithstanding the complexities of securitzation, credit default swaps, and capital ratios, it was a simple failure of consumer protection -- tolerance of massive underwriting fraud, abusive loan products like negative principal loans, incentives for loan officers to put people into higher-interest loans than they qualified for -- that blew up the credit bubble and provided the toxic material for all those toxic securities that brought the banks low and triggered the credit default swap obligations that threatened to bring the whole financial system to its knees.

That's not to say that banks could not find other stupid risks if they were prevented from deceiving retail customers and offering them excessive credit. Pay incentives and capital ratios are crucial, too. But if consumer protection is merely a "first step," it's also a first priority.

Is Obama signalling no more troops to Afghanistan?

2009-09-20T07:42:00.000-07:00

Slightly distorting Obama's words in the retelling, George Stephanopoulos headlines a blog post about his interview with Obama aired this morning:

President Obama: "Skeptical" on More Troops for Afghanistan

That's almost but not quite true. Per the exchange below, I think Obama was characterizing himself generally as "skeptical" when fielding military requests for more troops - skeptical as a matter of principle and habitual procedure.

Which is not to say that Stephanopoulos was not picking up a genuine signal. What struck me, below, was the way Obama characterized his March decision to send 21,000 more troops to Afghanistan:

STEPHANOPOULOS: You were for a flexible time line in Iraq. Some people now are saying that's exactly what should happen in Afghanistan if the same conditions hold. Do you agree with that?

OBAMA: Here's what I think. When we came in, basically, there had been drift in our Afghan strategy. Everybody acknowledges that. And I ordered a top to bottom review. The most important thing I wanted was us to refocus on why we're there. We're there because al Qaeda killed 3,000 Americans and we cannot allow extremists who want to do violence to the United States to be able to operate with impunity.

Now, I think we've lost -- we lost that focus for a while and you started seeing a -- a classic case of mission creep where we're just there and we start taking on a whole bunch of different missions.

I wanted to narrow it. I did order 21,000 additional troops there to make sure that we could secure the election, because I thought that was important. That was before the review was completed. I also said after the election I want to do another review. We've just gotten those 21,000 in. General McChrystal, who's only been there a few months, has done his own assessment.

I am now going to take all this information and we're going to test whatever resources we have against our strategy, which is if by sending young men and women into harm's way, we are defeating al Qaeda and -- and that can be shown to a skeptical audience, namely me -- somebody who is always asking hard questions about deploying troops, then we will do what's required to keep the American people safe.

Those troops were sent "to secure the election"? I don't believe that the stated rationale was that circumscribed when the deployment was announced. The reinforcements were sent to staunch an acknowledged deterioration in the fight to contain Taliban influence. Moreover, the effort to "stabilize" the election is universally acknowledged to have failed to prevent massive election fraud.

Does that retroactive mission-tightening suggest a current reluctance to commit more troops?

Political fantasy hour

2009-09-20T05:47:00.000-07:00

This Sunday's op-ed section in the Times includes two well-informed proposals for radical reform that will never happen, at least not any time soon. One is Tom Friedman's endlessly-reiterated call for a $1/gallon Federal tax on gasoline - an idea so eminently sensible that he's right to have spent decades rolling that stone up the hill. The other is economists Peter Boone and Simon Johnson's proposed five-year revolving door ban between Wall Street and the Federal government -- a ban not just on lobbyists moving back and forth, but financial executives too. This strikes me as a bit extreme, not to say Utopian -- some foxes do make good henhouse guards.

Reading the two policy wishes in tandem set me off on an "if I were king of the forest" fantasy. If I could change U.S. policy by fiat, what would I do? What's politically impossible but eminently sensible? For starters, I think Freidman is dead right -- taxing gasoline has made sense to me ever since Rep. John Anderson proposed it in the 1980 presidential campaign. A few other strays:

Ban political advertising. I've always thought the free speech defense was bullshit. The Constitution guarantees free speech, not the right to pay to broadcast your speech. e. I realize there's a long line of legal precedent on this issue, but I think it went in the wrong direction. Political advertising undermines real political discourse.
Single payer health insurance: all of the planned reforms to "bend the curve" on health care inflation would be more effective if the government were the only payer. The health insurance industry is parasitic -- it adds nothing constructive to health care delivery. Whatever Rube Goldberg system we patch together will be inferior to Canada's "Medicare for all."
End the subsidized private student loan industry: this is one more financial sub-industry that's purely parasitic - subsidized to exploit the young and squeeze profits out of government money directed to a social end.
Tear up the college "529" savings programs: I'd love to see the legislative/lobbying history of this boondoggle, in which each state hands a captive market over to a particular mutual fund company or handful of mutual fund companies, which offer a limited menu of investment options offered tax protection in that state. Who can tell me why college savings accounts are not structured like IRAs, allowing investors to qualify for the tax break while investing in whatever vehicles they choose?

This list should be far longer, but I'm sticking to pet peeves and no-brainers. So much for my shallow Sunday morning thinking for a Sunday morning.

The crown jewels of health care cost-cutting

2009-09-19T05:51:00.000-07:00

Ron Brownstein has an important post that details the substantial cost-control measures in the Baucus bill that led CBO to score it as a deficit reducer over the long term. The measures, Brownstein notes, center on two themes: "shifting the reimbursement model away from volume to value, and encouraging physicians to work more closely in teams to manage the overall health of patients, particularly those with expensive chronic conditions."

The Baucus bill would also create an empowered oversight commission, the "MedPAC on steroids" that Obama has emphasized as the chief mechanism for sifting, improving and expanding the cost control measures seeded in the bill. Brownstein:

The bill creates a second new institution that could be even more important: an independent Medicare Commission, as Obama has proposed. The commission would be required to offer proposals for cost-savings whenever Medicare spending rises too fast and Congress would be required to give their proposals fast-track consideration. The commission would likely become a vehicle to move into law the most promising payment and coordinated care reforms that emerge from the tests and pilot programs that the bill's other provisions set in motion. "If it develops into a respected independent body it could be one of the most significant parts of this legislation," said the senior administration officials. "I think that's the most auspicious path forward for promoting fundamental reform."

Compare Obama, speaking to Washington Post editor Fred Hiatt in July:

At this point, I am confident that both the House and the Senate bills will contain what we've been calling MedPAC on steroids, the idea that you continually present new ideas to change incentives, change the delivery system, understanding that because this is such a complex system we're not always going to get it exactly right the first time, and that there have to be a series of modifications over the course of a series of years, and we have to take that out of politics and make sure that an independent board of medical experts and health economists are providing packages that are continually improving the system. So I think there's general consensus that that is one of two very powerful levers to bend the cost curve.

Note the gradualism. That's not pusillanimity; it's recognition that our current payment system is a huge battleship that can only be turned by degrees. Compare Atul Gawande, who did so much to spotlight payment incentives as a core driver of health care inflation:

McAllen and other cities like it have to be weaned away from their untenably fragmented, quantity-driven systems of health care, step by step. And that will mean rewarding doctors and hospitals if they band together to form Grand Junction-like accountable-care organizations, in which doctors collaborate to increase prevention and the quality of care, while discouraging overtreatment, undertreatment, and sheer profiteering. Under one approach, insurers—whether public or private—would allow clinicians who formed such organizations and met quality goals to keep half the savings they generate. Government could also shift regulatory burdens, and even malpractice liability, from the doctors to the organization. Other, sterner, approaches would penalize those who don’t form these organizations.
This will by necessity be an experiment. We will need to do in-depth research on what makes the best systems successful—the peer-review committees? recruiting more primary-care doctors and nurses? putting doctors on salary?—and disseminate what we learn. Congress has provided vital funding for research that compares the effectiveness of different treatments, and this should help reduce uncertainty about which treatments are best. But we also need to fund research that compares the effectiveness of different systems of care—to reduce our uncertainty about which systems work best for communities. These are empirical, not ideological, questions. And we would do well to form a national institute for health-care delivery, bringing together clinicians, hospitals, insurers, employers, and citizens to assess, regularly, the quality and the cost of our care, review the strategies that produce good results, and make clear recommendations for local systems.
Dramatic improvements and savings will take at least a decade...

Bending the health care cost curve is not the work of a day, or a single bill. There is a fair amount of consensus among Democrats about how to get the process started. Will the lobbyist-ridden legislative process gut the promising provisions drafted in Baucus's and other bills? Will Obama take a stand on these, as he didn't on the public option? Did he decide long ago that payment mechanisms were more important than insuring mechanisms?

Boehner gives the game away on missile shield in Eastern Europe

2009-09-18T04:49:00.000-07:00

John Boehner's denunciation of Obama's cancellation of the missile shield deployments in Poland and the Czech Republic shows what the plan was always really about:

“Scrapping the U.S. missile defense system in Poland and the Czech Republic does little more than empower Russia and Iran at the expense of our allies in Europe,” said Representative John A. Boehner of Ohio, the House Republican leader. “It shows a willful determination to continue ignoring the threat posed by some of the most dangerous regimes in the world.”

Note the sequencing of threats in this knee-jerk reaction. What does that say about Bush's repeated protestations that the shield had nothing to do with Russia?

And don't expect any subtlety from John McCain, enabler-in-chief of that Georgian fool's Saakashvili's furnishing of a pretext for Russian intervention in 2008:

“I fear the administration’s decision will do just that [undercut allies],” Senator John McCain, Mr. Obama’s Republican rival in last year’s presidential election, said Thursday, adding that the decision came “at a time when Eastern European nations are increasingly wary of renewed Russian adventurism.”

The Poles and Czechs, meanwhile, seem to have been concerned mainly to get American boots on their soil, whatever the pretext. They're about as worried about Iran as we are over incoming meteoroids.

The decision's possible downside -- raising Polish and Czech anxieties, perhaps emboldening Russia with an unforced 'concession' over a program that allegedly had nothing to do with them--does highlight what may be the signature challenge of the Obama Administration: unraveling bad policies that entail real commitments to various parties.

Wydening the insurance exchange

2009-09-17T08:13:00.000-07:00

Senator Ron Wyden has taken a slice out of the widely respected but off-the-table Wyden-Bennett health care reform bill, which would put all Americans in a national insurance exchange, to propose now that all Americans share the opportunity to opt into an insurance exchange:

I believe there is a way to work with the present employer-based system to guarantee that all Americans have choices, and I am proposing it in an amendment to the latest Senate health care bill. My amendment, called Free Choice, would let everyone choose his health insurance plan.
It would impose only one requirement on employers — that they offer their employees a choice of at least two insurance plans, one of them a low-cost, high-value plan. Employers could meet this requirement by offering their own choices. Or they could let their employees choose either the company plan or a voucher that could be used to buy a plan on the exchange. They could also simply insure all of their employees though the exchange, at a discounted rate.

Could this widening of the exchange pool serve some of the purpose of a public option, e.g., by providing critical mass to health care co-ops? And shouldn't that partial individualizing of the health care market appeal to Republicans?

Ezra Klein reports that Obama met with Wyden and Bennett as well as with Jay Rockefeller. Could a final bill staple together Baucus's deficit-reducing funding mechanism, the bigger subsidies that Rockefeller wants (as do liberal Democrats generally), and Bennett's "privatizing" amendment? Could compromise actually improve the bill that becomes law? We can dream, can't we?

Is a specter haunting Chinese communism?

2009-09-15T17:23:00.000-07:00

Back in May, I humbly questioned the conclusions drawn by the authors of an intense statistical study* of the factors contributing to nations' transitions to democracy (humbly, because the researchers' numbers crunching is way beyond me; I was only looking at the conclusions they drew from statistical patterns they themselves identified). The authors concluded that economic growth in non-democratic states does not foster democracy, because their data showed that states experiencing strong GDP growth generally do not make the transition.

But while growth may not trigger a change in government while it's happening, perhaps change tends to come after a period of rapid growth, during a sudden onset of economic stress. People whose standard of living has risen and whose expectations have risen faster may be more inclined than their poorer forbears to hold an autocratic government accountable when it fails (or seems to fail) to deliver the goods.

China's rulers seem to live under the shadow of this possibility. Gideon Rachman, assessing the pace at which China may be moving toward world leadership, notes:

The government’s neurotic obsession with achieving its totemic figure of 8 per cent growth a year hints at the country’s continuing political fragility. Without a democratic mandate, the Communist party relies on rapid growth to keep the system stable. Somehow the country needs to make the transition to a system in which the government can draw upon alternative sources of legitimacy. Twenty years after the Tiananmen massacre, the Communist party shows no outward sign of contemplating a transition to a more democratic system. Meanwhile, the Chinese media speculate openly that social unrest could rise to dangerous levels, if economic growth slackens.

Over time, China may yet prove the much-maligned Francis Fukuyama right in his contention that competitive economic pressure is pushing all countries toward liberal democracy. Fukuyama hedged that hypothesis in various ways and never suggested that the "end of history" was at hand as he wrote. It seems to me that the jury is still very much out.

*Extreme Bounds of Democracy, by Martin Gassebener, Michael J. Lamia and James Raymond Vreeland

David Frum is making sense

2009-09-15T11:29:00.000-07:00

David Frum has a simple syllogism for Republicans on health care:

a) If you succeed in killing health care reform this time around, health care costs will spiral out of control
b) If health care inflation is not curbed, the United States will never see another tax cut
c) What are Republicans for, anyway?

Frum is in sustained combat with the wackos that have taken over his party. And he's serenely confident that he will win:

We have been besieged but this is a fight worth doing. And I have to say I'm thinking of changing our slogan. I'm adapting something from the old Panasonic folks, our new motto's going to be "just slightly ahead of our time." I know the conservatives of this country are not with me on these issues today. But I know equally well they will be with me on these issues in the future. They are just going to learn it, unfortunately, a harder way.

Let's hear it for good old-fashioned courage.

Osama's amended complaint

2009-09-14T08:04:00.000-07:00

The latest alleged Osama bin Laden tape "reminds" Americans:

We have demonstrated and stated many times, for more than two-and-a-half-decades, that the cause of our disagreement with you is your support to your Israeli allies who occupy our land of Palestine.

Was not Osama's original causus belli the United States' "occupation" of the sacred soil of Saudi Arabia during and after the 1991 Gulf War?

Yes, Israel is always there as a stand-by, but in Osama's 1998 fatwa ordering Muslims to kill Americans wherever they can, U.S support of Israel is a paltry third justification, trailing 1) "occupying the lands of Islam in the holiest of places, the Arabian Peninsula, plundering its riches, dictating to its rulers, humiliating its people, terrorizing its neighbors, and turning its bases in the Peninsula into a spearhead through which to fight the neighboring Muslim peoples" and 2) "Americans' continuing aggression against the Iraqi people using the Peninsula as a staging post."

In the latest tape, Osama (if the tape is authentic) asserted that Obama is "powerless" to stop the war in Afghanistan and in the grip of the "pro-Israel lobby." But surely Osama's intended audience is aware that Obama is mistrusted and unpopular in Israel. If this tape is authentic, it seems a particularly lame indictment, even from a violent Jihadist's point of view.

On "catching" happiness

2009-09-13T17:37:00.000-07:00

According to the research team Nicholas Christakis and James Fowler, pioneers in the study of "social contagion," happiness is a large social network. From Clive Thompson's long assessment of their research in the Times Magazine:

The subconscious nature of emotional mirroring might explain one of the more curious findings in their research: If you want to be happy, what’s most important is to have lots of friends. Historically, we have often thought that having a small cluster of tight, long-term friends is crucial to being happy. But Christakis and Fowler found that the happiest people in Framingham were those who had the most connections, even if the relationships weren’t necessarily deep ones.
The reason these people were the happiest, the duo theorize, is that happiness doesn’t come only from having deep, heart-to-heart talks. It also comes from having daily exposure to many small moments of contagious happiness. When you frequently see other people smile — at home, in the street, at your local bar — your spirits are repeatedly affected by your mirroring of their emotional state. Of course, the danger of being highly connected to lots of people is that you’re at risk of encountering many people when they are in bad moods. But Christakis and Fowler say their findings show that the gamble of increased sociability pays off, for a surprising reason: Happiness is more contagious than unhappiness. According to their statistical analysis, each additional happy friend boosts your good cheer by 9 percent, while each additional unhappy friend drags you down by only 7 percent. So by this logic, adding more links to your network should — mathematically — add to your store of happiness. “If you’re at the center of a network, you are going to be more susceptible to anything that spreads through it,” Fowler said. “And if happiness is spreading more reliably, then on average you’re going to be catching happy waves more often than you catch sad waves.”

This sweeping claim set off a series of free associations in me, an inveterate introvert. E.g.:

1) Walking to work in Manhattan, where I might pass 1,000 people on my mile-long route, I've noticed that people look a lot better when they're with someone else -- happier, more intelligent, more energetic.

2) As Atul Gawande documented ably some months ago, solitary confinement is torture. It has taken hold through what also might be a kind of social contagion in the U.S. over the past quarter century:

Prolonged isolation was used sparingly, if at all, by most American prisons for almost a century. Our first supermax—our first institution specifically designed for mass solitary confinement—was not established until 1983, in Marion, Illinois... In 1995, a federal court reviewing California’s first supermax admitted that the conditions “hover on the edge of what is humanly tolerable for those with normal resilience.” But it did not rule them to be unconstitutionally cruel or unusual...The ruling seemed to fit the public mood. By the end of the nineteen-nineties, some sixty supermax institutions had opened across the country. And new solitary-confinement units were established within nearly all of our ordinary maximum-security prisons.
The number of prisoners in these facilities has since risen to extraordinary levels. America now holds at least twenty-five thousand inmates in isolation in supermax prisons. An additional fifty to eighty thousand are kept in restrictive segregation units, many of them in isolation, too, although the government does not release these figures.

3) The former king of the Himalayan kingdom Bhutan, Jigme Singye Wangchuck, may have been onto something with his concept of Gross National Happiness as an aim of government policy. But perhaps instead of focusing on sustainable development, cultural values, environment conservation and good governance he should have focused on increasing social interaction.

4) I have often wondered whether people in countries that are poor but still organized around tight social networks, such as tribes, mightn't be happier on average than people in advanced industrial societies -- that is, if the country is not a failed state or ruled by a brute like Saddam, or by a regime that deeply intrudes upon and controls and distorts social and economic life, like Iran's.

5) On the other hand, the ancient pastoral ideal and classical dichotomy between the wholesome country life and the sordid, corrupt city is more or less a load of crap -- as are demagogues' paeans to the virtues of small town America. While cities can be places of both horrific isolation, human beings have at every opportunity voted with their feet -- and hearts, and minds - to place themselves in ever larger social hives.

6) Per items 4 and 5, I really have very little idea where human social life is most rewarding. I really should get out more. But it does seem that organizing ourselves in ways that maximize positive social interaction is the fundamental challenge of human collective effort. Perhaps Wangchuck's four pillars of "GNH" are at bottom means to that end.

A Distant Mirror in Iran

2009-09-12T06:15:00.000-07:00

Mohammad Sahimi at Tehran Bureau has a magisterial, level-headed, fact-crammed, on-the-on-hand-on-the-other-hand overview of the situation in Iran that should not be missed (h/t Gary Sick). It's a Rorschach test for those with hopes or fears or strong opinions about Iran, in that it details the weaknesses of the hardliners' position as well as the full implications of the fact that the ruling clique has all the guns and Mafioso-style control of the economy.

I would not presume to add my thinly informed two cents to this deeply informed analysis. But one free association is perhaps worth recording. It was triggered by one item in a list of challenges faced by the ruling hardliners:

Secondly, the Ahmadinejad group is totally devoid of intellectuals and deep thinkers who can lead or even show the way to improving the economy. Most moderate conservative experts have fled the Ahmadinejad camp. The composition of his new government, which is totally devoid of any “heavy weight” expert, is highly illustrative of that fact.

This gave me a flash image of the U.S. after a Palin-led or other extreme rump Republican takeover -- enabled perhaps after a nuclear terrorist attack (Joe the President, anyone?). Our system has stronger antibodies than Iran's, but who's to say it couldn't happen? The Bush Administration went a ways down this road, packing the Justice Department, EPA and countless other agencies with faith-based ideologues and industry shills; it went a long way toward bankrupting the country with a 1-2-3 punch of tax cuts for the wealthy, entitlement giveaways and unnecessary war; it further undermined institutional norms and taboos by cooking the intelligence-gathering process and instituting a torture regime; it stimulated and materially aided what Andrew Sullivan calls "movement conservatism, the business," i.e. the entertainment juggernaut of mainstreamed Father Coughlin-level demagoguery.

We're in partial remission at the moment. But the radicalization of the Republican rump is dangerous; demagogues are waiting in the wings. The country needs two parties capable of governing. As of now, we don't have that.

Obama "triggers" a recount of heath care bills' costs

2009-09-11T10:30:00.000-07:00

David Brooks would have us believe that Obama's promise in Wednesday night's speech not to sign a health care bill if it "adds one dime to the deficit" "kills the kills the House health care bill," which allegedly would add $220 billion to the deficit over ten years.

But as Ezra Klein highlights for us, Obama's very next sentence indicates an intent to change the CBO scoring that determines each bill's alleged price tag. As several observers including John R. Gabel have pointed out, the CBO has a history of underestimating the savings from various enacted Congressional measures to reduce health care costs; it's difficult for lawmakers to get due credit for cost-cutting measures. Hence this proposal, immediately following the "dime" pledge:

And to prove that I’m serious, there will be a provision in this plan that requires us to come forward with more spending cuts if the savings we promised don’t materialize."

Klein, I believe, had already flagged this possibility prior to Obama's speech (it was either him or Cohn). Today, he's all over it:

The idea was recently explained in a paper David Cutler and Judy Feder wrote for the Center for American Progress, so I called Feder today to ask what, exactly, the president was talking about.
How does a fiscal trigger work?

The idea of a trigger is that one establishes in advance a target for savings in the system, agrees on measures that need to be achieved, track that progress as the program is implemented, and if shortfalls are found, then certain actions are automatically triggered in.

What are those actions? What happens when you pull the trigger?

David Cutler and I put forward a range of options and believe a menu should be specified in the legislation. That menu could include further reductions in Medicare or changes in the tax treatment of employer-based efficiency or a strengthening of a public plan to further competition with insurers.

And why do we need this? I thought the plan already had savings in it.

The reason that David Cutler and I have been so supportive of a trigger is that we are firmly behind the cost-saving measures that are in legislative proposals and on which there is enormous agreement to change the health-care delivery system. Payment reform, a value-based purchasing system, moving away from the overprovision of low-value and high-cost procedures, and rewarding providers for better care and management of chronic illness. There's work and experience showing those measures can achieve huge savings systemwide. David Cutler and Rand's Melinda Buntin estimated (pdf) the savings at $2 trillion over the next decade.

But CBO is very cautious about scoring those measures. So it's our belief that for scoring purposes, we can put underneath them a failsafe that guarantees CBO will score the savings.

So the idea is that those savings will appear, but since CBO won't score them, you basically give CBO something it can score that's of similar value?

Exactly.

Presto. That house bill might be scored differently. More importantly, it may really accelerate the imposition of serious cost controls, i.e. changes to the fee-for-service payment structure, which by their nature must be incremental. Read the whole of Klein's interview of Feder.

The invisible 1/3 of U.S. health care funding

2009-09-11T06:10:00.000-07:00

Trickling through news reports and blogs are 2008 census figures showing an accelerating shift away from employer-based and toward government-supplied health insurance. Employers in 2008 covered just 58.5% of Americans, down from 59.3% in 2007 and 64.2% in 2000.

What's often not noted in the health care debate is a parallel shift by employers from providing traditional insurance, supplied by an insurance company, to providing self-funded health care plans, generally administered by an insurance company or other "third party administrator" (TPA) and backed by catastrophic "stop-loss" insurance.

More than half of Americans who get their health coverage from their employers are in self-insured plans (the last figure I remember seeing is 55%), which are not subject to state mandates. There are more people whose health care is funded directly by their employer than by government plans, and almost as many as are insured by private health insurers (whether employer-provided or purchased directly).

Per the numbers below, presented by the Council of Economic Advisor's Cecilia Rouse and flagged by Ben Smith, little more than one third of Americans are covered by traditional private, third-party health insurance plans (a bit less than half of the 58.5% with employer-based coverage, plus approximately 9% who buy insurance directly).

Some questions worth answering: how does employer-funded health care stack up against traditional private insurance? How successful are employers at controlling costs -- are they completely in the hands of their TPAs? What percentage of health insurers' income comes from administering companies' self-funded plans, or from providing stop-loss to self-funded companies? To what extent will new health care legislation regulate employer-funded benefits? In addition to providing health insurers with a new pool of subsidized shoppers, will health care legislation offer them new opportunities to act as administrators?