No matter how difficult the issue, Obama has been sensible, deliberative. Just look at Dick Cheney swooping around like a dementor from Harry Potter, and you have to appreciate how much things have improved.
MR. RUSSERT: In order to pay for this war, would the president consider suspending his proposed tax cut?
VICE PRES. CHENEY: We don’t believe that’s the right course of action, Tim. This is one of those times when as important as the war on terror is and as important as the problem of Iraq is, we’ve also got a lot of other balls in the air. And an American president these days doesn’t have the choice of focusing on only one thing. We’ve also got to deal with the Middle East peace process, with Israelis and Palestinians which we did this week. We’ve got to deal with the domestic economy. It’s very important to get the economy growing again. And one of the reasons we’ve had a fall-off in revenue, obviously, is a slow economy and we need to get growth started again....
While Al Qaeda is under great pressure now and dependent on the Taliban and other extremist groups for sustainment, the success of the Taliban would vastly strengthen Al Qaeda’s message to the Muslim world: that violent extremists are on the winning side of history. Put simply, the Taliban and Al Qaeda have become symbiotic, each benefiting from the success and mythology of the other. Al Qaeda leaders have stated this explicitly and repeatedly.
Holbrooke called the nine weeks of recent White House meetings on the war “the most careful, detailed, methodical policy review I’ve ever been involved in.” The basic conclusion: “You can’t separate the Taliban from Al Qaeda at this point. Our judgment is that if the Taliban succeed in Afghanistan, they will bring back Al Qaeda with them,” as well as score an enormous psychological victory for extremists worldwide.
Give me a sceptic and I will take him to Shanghai or São Paulo on a day of ripe smog and see how sceptical he remains while coughing his guts into a mask and peering at brown sunlight as if through a dome of begrimed glass. Lake Baikal is a saline puddle and the Sahara is heading for Timbuktu. If the earth is not yet in its terminal death rattle, it sure ain’t looking good. Population pressure on shrinking and degraded resources in the poorest parts of the world is unrelenting and no mega-city – Lagos, Caracas, Rio, Mumbai – is without its mountain range of trash on which humans can be seen like skeletal goats picking over the black plastic for something to eat. Along with drought and famine, pandemics have returned: in which, like some as yet unwritten scripture, the animal kingdom – avian, porcine, bovine – is a bellwether of human perishability.
All of which seems to put the nail in the coffin of a collective optimism born 200 years ago, when the Enlightenment envisioned a world illuminated by reason, banishing the afflictions of ignorance, poverty, war and disease. hat the arch-prophet of this smiley-faced secularism, the Marquis de Condorcet, perished while imprisoned by French revolutionary authorities should have told us something.Whew. Well, key up the guillotine for Condorcet Jr. -- that is, me, a.k.a. Pollyanna the Fukuyaman, giving way to a fit of knee-jerk contrarian optimism. I'm used to this. My poor mother (born in 1933 and still commuting to Manhattan 3x a week) witnessed the crumbling of WTC Tower #2 with her own eyes on 9/11. I've been trying to convince her ever since that humanity remains on an upward trajectory, that the Soviet Union was a more dangerous adversary than al Qaeda, etc. etc. So for what it's worth, a reality check on the last decade:
As we are gathered here, according to the information reaching us, all the major cities of Iran are closed down: Tehran, Tabriz, Mashhad, Qum...
The people have identified the true criminal. It was obvious before, it is true, but some people didn't recognize him as such or didn't dare speak out. Thanks be to God, this barrier of fear has collapsed and the people have discovered the true criminal and come to understand who is responsible for the misery of our nation.
The center for religious learning in Qum has proven its vitality; the people of Qum and the respected students of the religious sciences have fought the government...with their bare hands, with a courage rarely equalled in history, and yielded their martyrs. When the agents of the regime spilled into the streets and alleyways of Qum and attacked the people--according to the reports we have received--the people resisted them to the utmost degree possible, both before and after the massacre, thus proving how alive they are. They proved that they were alive, not dead!
- Ayatollah Ruhollah Khomeini
"In Commemoration of the First Martyrs of the Revolution"
February 19, 1978
For those who dismiss the bill as a giveaway to insurance companies, Pear serves up a deadpan rebuttal:
Senate Passes Health Care Overhaul Bill
WASHINGTON — The Senate voted Thursday to reinvent the nation’s health care system, passing a bill to guarantee access to health insurance for tens of millions of Americans and to rein in health costs as proposed by President Obama.
The 60-to-39 party-line vote, on the 25th straight day of debate on the legislation, brings Democrats a step closer to a goal they have pursued for decades. It clears the way for negotiations with the House, which passed a broadly similar bill last month by a vote of 220 to 215.
The bill would establish stringent federal standards for an industry that, since its inception, has been regulated mainly by the states.
Under the bill, insurers could not deny coverage because of a person’s medical condition; could not charge higher premiums because of a person’s sex or health status; and could not rescind coverage when a person becomes sick or disabled. The government would, in effect, limit the profits of insurers by requiring them to spend at least 80 to 85 cents of every premium dollar on medical care.
The specificity of federal standards is illustrated by one section of the bill, which requires insurers to issue a summary of benefits that “does not exceed four pages in length and does not include print smaller than 12-point font.”
I don't think this is about a short term five point bump. Here's what has happened: a liberal Democratic president has just passed universal health insurance. No Democratic president has done something like that since Johnson. It is designed to show that government can do something real and tangible for the working poor. And in that respect, its impact on the political culture will be deep and lasting, unless the opposition can stop it, demonize it, or jump up and down enough to make it seem as if Obama is out of step with the times rather than them.
My suspicion is that they will fail in the end to achieve this; and that this new landmark for liberalism will reorient American politics the way Reagan's first year did - profoundly.
Leadership aides say progressives are prepared to take it on the chin and will vote for a final bill without a public option. But they say pro-life Democrats will seek direction from the U.S. Conference of Bishops as to whether they can support an amendment weaker than Rep. Bart Stupak's, thus setting up what will likely be the most difficult negotiation before a final vote.Catholic bishops have about as much credibility on matters of sexual and reproductive morality as Iranian mullahs have with respect to vote-counting.
“I’ve seen man at his worst, and man at his best. I can tell you that in the darkest of moments, there are those who provide a light. Never forget that a small beam of light is enough to overpower a whole room of darkness. Never underestimate the impact that you alone, sticking to your principles, can have.”- Ali Soufan, former FBI rapport-based interrogator extraordinaire, nemesis of the Cheney torture regime
A speculative frenzy of borrowing and bidding up is at work. If and when prices crash, there will be hell to pay.
Signs of the times: government bureaucracies funding themselves by foisting debt on state-owned business enterprises; local governments raising capital by selling land at sky-high prices to corporations they own; and a People's Bank of China lavishing liquidity on the entire system in a way that makes Federal Reserve Chairman Ben Bernanke look downright stingy.
"I just look at this institution as really the last bastion of protecting the rights of the minority, and we should be very careful before we try and make any changes."
- Senator John Warner (R-VA), April 19, 2005
And most dangerously, we see it in the way that religion is used to justify the murder of innocents by those who have distorted and defiled the great religion of Islam, and who attacked my country from Afghanistan. These extremists are not the first to kill in the name of God; the cruelties of the Crusades are amply recorded. But they remind us that no Holy War can ever be a just war. For if you truly believe that you are carrying out divine will, then there is no need for restraint -- no need to spare the pregnant mother, or the medic, or the Red Cross worker, or even a person of one's own faith. Such a warped view of religion is not just incompatible with the concept of peace, but I believe it's incompatible with the very purpose of faith -- for the one rule that lies at the heart of every major religion is that we do unto others as we would have them do unto us.Osama's favorite label for U.S. and western forces is "crusaders." Obama pointedly puts the European Crusaders of old on the same side of the ledger as Islamic extremists. No holy war can ever be a just war. One rule lies at the heart of all religions. Obama is simultaneously taking on the militant understanding of jihad and denying any fundamental clash of civilizations. Mullahs of the world, mull that.
Supporters of the public option want it to remove the profit motive as an obstacle to medical care, and also to menace the private insurance companies that they generally view as greedy and mean. At times, some lawmakers seemed to favor the public plan simply because private insurers hate the idea.The point of the public option is not to punish or necessarily weaken the private insurance industry. A strong public option would aim its firepower at providers more than at insurers. That is, by tying repayment rates to Medicare rates, it would bring a wider swath of this country's patchwork of health care payments under the aegis of the Federal government. In other words, it would move the U.S. health care market one step closer to monopsony, the sine qua non of universal health care in every country that offers it -- a market in which the government sets the prices (and coverage rules) for all health care services. That ultimately should improve the pricing power of private insurers competing against a public option; for all the industry's cries about "cost-shifting," the net result of increased government pressure on pricing is likelier to be more pricing power for all buyers.
While alleging that unforced errors have undermined support for President Obama's domestic agenda, Clive Crook asserts with regard to the health care reform bills in Congress that "the administration has not yet credibly accounted for the costs or said how it will meet them."
Come again? The CBO has scored both House and Senate bills as deficit-reducers. Obama has stressed cost control throughout the process, and the Democrats' fiscal responsibility in crafting this bill stands in dramatic contrast to Republicans' ramming through the deficit-financed Medicare drug coverage bill in 2003 (not to mention their reckless tax-cutting in war time).
Mr. Crook simply has not faced up to the effect on public opinion of the Republicans' relentless lying about the health care reform bills. And still, after witnessing Republicans' bad-faith stonewalling on both the stimulus and health care reform, he dreams that Obama might work with a coalition of Republicans and centrist Democrats on tax reform. If he thinks that Republicans would join with centrist Democrats to work with Obama on anything he is truly a brother from another planet where American politics is concerned.
Obama is "remoulding" America, as Mr. Crooks suggests he might if he'd only follow Mr. Crook's prescriptions. No one ever said it would be easy. His poll numbers will go down as Reagan's did until the economy unmistakably turns around and the effects of passing health care reform sink in. Then watch the battleship turn.
"Opposition leaders are trying to calm them [the students] down and prevent any kind of violent clash that could harm the movement in a way that could be irreversible... it seems like the students are moving ahead of their leaders and it's not going to be easy for anyone to control the situation."
There was no consensus yet on troop numbers, however, so Mr. Obama called a smaller group of advisers together on Oct. 26 to finally press Mrs. Clinton and Mr. Gates. Mrs. Clinton made it clear that she was comfortable with General McChrystal’s request for 40,000 troops or something close to it; Mr. Gates also favored a big force.Here is the part of Obama's speech that lays out the thinking behind this change of plan:
Mr. Obama was leery. He had received a memo the day before from the Office of Management and Budget projecting that General McChrystal’s full 40,000-troop request on top of the existing deployment and reconstruction efforts would cost $1 trillion from 2010 to 2020, an adviser said. The president seemed in sticker shock, watching his domestic agenda vanishing in front of him. “This is a 10-year, trillion-dollar effort and does not match up with our interests,” he said.
Still, for the first time, he made it clear that he was ready to send more troops if a strategy could be found to ensure that it was not an endless war. He indicated that the Taliban had to be beaten back. “What do we need to break their momentum?” he asked.
Four days later, at a meeting with the Joint Chiefs of Staff on Oct. 30, he emphasized the need for speed. “Why can’t I get the troops in faster?” he asked. If they were going to do this, he concluded, it only made sense to do this quickly, to have impact and keep the war from dragging on forever. “This is America’s war,” he said. “But I don’t want to make an open-ended commitment” (my emphasis).
As President, I refuse to set goals that go beyond our responsibility, our means, or our interests. And I must weigh all of the challenges that our nation faces. I don't have the luxury of committing to just one. Indeed, I'm mindful of the words of President Eisenhower, who -- in discussing our national security -- said, "Each proposal must be weighed in the light of a broader consideration: the need to maintain balance in and among national programs."
In my years on the ground in Afghanistan, I witnessed the catastrophic under-resourcing of civilian rule. In 2001, there were 240,000 civil servants in place in Afghanistan, staffing schools, clinics, irrigation departments and ministries across Afghanistan’s provinces. The decision taken in 2002 was to ignore these public servants and the services they ran, by putting only $20 million in the Afghan Government’s first-year budget.According to Lockhart, the Afghan government had "a broad measure of trust" from the Afghan people from 2001-2005 but was starved of resources and capacity by the channeling of development aid to international NGOs. (A bit of context: Ashraf Ghani, Lockhart's colleague at the Institute for State Effectiveness and co-author with her of Fixing Failed States, was Afghan finance minister from 2002-2004.) She offers a measure of enthusiasm and hope that jars with the rueful "mission-all-but-impossible" attitude of most informed insiders making themselves heard in English-language media.
This barely paid fuel costs for a month, let alone salaries of $50 per month or the costs of schools and clinics. Instead, billions went into a parallel aid system and into supporting warlords to run militias that daily undermined the rule of law. The net result was to dismantle functioning Afghan institutions; teachers and nurses left their jobs in droves to become drivers, assistants and translators...
Change needs to come not only from the Afghans, but the way that international actors operate. The aid system requires a thorough revamping, so that it no longer undermines the very institutions it claims to support. This will require measures such as limiting the wages paid to Afghan staff working in the aid system to the same level they would earn in Afghan ministries.
Tired Soldier: Won't increasing numbers of U.S. troops lead to more contact (combat) and further alienate the civilian population? In my experience in Afghanistan, more contact has always meant more fire support gets used, which means more civilians get killed, which turns the local tribal elders against us and multiplies our enemies. General McChrystal hasn't been able to break that cycle yet. Any sense that the new strategy avoids this trap?
Steve Coll: It's a good question. The McChrystal report suggests that he expects more contact and more violence initially, but then hopes to "hold" and "build" in a more passive manner in the major population centers, once they are cleared of Taliban cells and networks. The level of violence in the big cities even now is not very intense, but that may change as international forces try to make themselves more felt in places like Kandahar. Apparently the new strategy will also recommit to rural Helmand province, a poppy-growing region. I'm not sure whether the Taliban will see it as in their interest to go all out there, given that they have other targets that will be less heavily defended, but in the short run, I would expect violence in Helmand to rise for the reasons you suggest. Already, however, the international community has some tribal and other allies in Helmand to work with on their side of the conflict.
The American military has long resisted hard and public timetables for ending military missions, on the assumption that a deadline merely lets the bad guys know how long they have to wait out American troops before moving in. That precise criticism was immediately heard from Republicans.In April 2007, when Republicans partisans were crying treason at Democrats seeking to impose a timetable on U.S. troop presence in Iraq, Gates famously said, “Demands in the U.S. Congress for a timeline to withdraw American troops from Iraq are constructive because they exert pressure on Iraq’s leaders to forge compromises.” He added: “The strong feelings expressed in the Congress about the timetable probably has had a positive impact . . . in terms of communicating to the Iraqis that this is not an open-ended commitment.”
Mr. Obama, in a lunch at the White House with a few columnists hours before he delivered his nationally televised speech on Afghanistan policy, countered that in this case the deadline for an American withdrawal is crucial to create leverage on Mr. Karzai to move with real urgency to improve his government and its security forces so they can take over the task of fighting the Taliban.
"That's exactly why we thought a timetable was so important," Mr. Obama said. "Because in the absence of a time frame, if the view in Afghanistan is this is an open-ended commitment or an indefinite commitment, then I think we have very little leverage" over the Afghan leader.
“After the President has repeatedly ignored the will of Congress and the American people, his own Secretary of Defense now recognizes that the only way to pressure the Iraqi government toward a political settlement is to make clear that American troops will not be in Iraq forever.The cross-fertilization in the thinking of Gates and Obama has been going on for quite some time.
The other argument is that we can sort of stand pat, whether it's at 30,000 or 40,000 or 50,000, you have some platform there, you're basically pulled back and hunkered down but you're able to prevent Kabul from being overrun; you can still project some counterterrorism operations in the region. The problem there is whether that level is 50 or 60 or 70, you have sort of a flatline, where there is no inflection point, there's no point at which, we can say conditions have changed conditionally sufficiently so that we can start bringing our troops home.
The best Afghan policy would be to reduce the number of foreign troops from the current level of 90,000 to far fewer – perhaps 20,000. In that case, two distinct objectives would remain for the international community: development and counter-terrorism. Neither would amount to the building of an Afghan state or winning a counter-insurgency campaign. A reduction in troop numbers and a turn away from state-building should not mean total withdrawal: good projects could continue to be undertaken in electricity, water, irrigation, health, education, agriculture, rural development and in other areas favoured by development agencies. Even a light US presence could continue to allow for aggressive operations against Al Qaeda terrorists, in Afghanistan, who plan to attack the United States. The US has successfully prevent Al Qaeda from re-establishing itself since 2001 (though the result has only been to move bin Laden across the border.). The US military could also (with other forms of assistance) support the Afghan military to prevent the Taliban from seizing a city or taking over the country.
While, I strongly oppose troop increases, I equally strongly oppose a total flight. We are currently in danger of lurching from troop increases to withdrawal and from engagement to isolation. We are threatening to provide instant electro-shock therapy followed by abandonment. This is the last thing Afghanistan needs. The international community should aim to provide a patient, tolerant long-term relationship with a country as poor and traumatized as Afghanistan. Judging by comparable countries in the developing world (and Afghanistan is very near the bottom of the UN Human Development index), making Afghanistan more stable, prosperous and humane is a project which will take decades. It is a worthwhile project in the long-term for us and for Afghans but we will only be able to sustain our presence if we massively reduce our investment and our ambitions and begin to approach Afghanistan more as we do other poor countries in the developing world. The best way of avoiding the mistakes of the 1980s and 1990s – the familiar cycle of investment and abandonment which most Afghan expect and fear and which have contributed so much to instability and danger - is to husband and conserve our resources, limit our objectives to counter-terrorism and humanitarian assistance and work out how to work with fewer troops and less money over a longer period. In Afghanistan in the long-term, less will be more.The alternative to Obama's surge put forward by Stewart is not, per the argument framed by Obama, maintaining a mid-sized force too small to improve the status quo until we get exhausted. It's to keep a force (and aid effort) that we can maintain for decades to foster a development that will take decades. Stewart might argue (he hasn't) that his strategy is comparable to securing one's financial future with a $1000 yearly term life insurance payment, whereas Obama's is comparable to slapping down six figures in a risky derivative bet.
Taken together, these additional American and international troops will allow us to accelerate handing over responsibility to Afghan forces, and allow us to begin the transfer of our forces out of Afghanistan in July of 2011. Just as we have done in Iraq, we will execute this transition responsibly, taking into account conditions on the ground. We will continue to advise and assist Afghanistan’s Security Forces to ensure that they can succeed over the long haul. But it will be clear to the Afghan government – and, more importantly, to the Afghan people – that they will ultimately be responsible for their own country.This analogy was Obama's chief device for arguing the claim that the swiftness of an envisioned drawdown of forces in Afghanistan will be almost directly proportional to the swiftness of the coming troop buildup.
The Kanjorski amendment recognizes that the systemic and societal danger posed by banks can be hard to recognize, and it proposes a number of potential objective criteria that could be used by the Financial Services Oversight Council (to be created by legislation in progress) to determine when banks need to be broken up, including the “scope, scale, exposure, leverage, interconnectedness of financial activities, as well as size of the financial company.”
The Kanjorski amendment does not impose a hard size cap on banks, but lawmakers in the House are discussing amendments that would do so.
There is, of course, a strong precedent for capping the size of an individual bank: The United States already has a long-standing rule that no bank can have more than 10 percent of total national retail deposits.
"Where we have gone, goodness follows," Conway said. "But the fact is that we are not as expansive as we would like to be, and those probable additional number of Marines are going to help us to get there."Next, an account of what sounds like a talent war - or corporate raid:
The administration's new plans for the Afghan army and police, which will probably be a heavy focus of Tuesday's speech, call for increasing the size of the army to about 134,000 troops by next October, four years earlier than the initial goal of 2014. To meet that target, the Afghan Ministry of Defense must bring in about 5,000 new recruits a month and dramatically cut attrition in existing battalions. In November, the defense ministry missed its monthly recruiting goal by more than 2,000 troops.
Afghan soldiers and police were recently given a 40 percent pay increase, but it is too early to tell whether the extra money will fix the recruiting problem, U.S. officials said.
"The extra pay literally brought us to parity with what the Taliban are offering," a senior military official in Kabul said.
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).
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).
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.
"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:
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 rareInteresting 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!
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."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.”
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."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.
As OMB Director Peter Orszag noted in an interview, the Reid bill met all those tests.
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: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.
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.
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."
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.
"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.
"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 knowRead the whole thing(s), parts 1-4 of Fallows' critique of media coverage of the trip.
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.
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."Positively effusive is Jonathan Gruber of MIT:
As OMB Director Peter Orszag noted in an interview, the Reid bill met all those tests.
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.
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:
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.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.
Our message to the Taliban is that they should take part in the government - Male, HeratOne 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.
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
