I sat down to write this post minutes after the Senate passed its health care bill.  Computer problems and then Christmas have intervened.  We enjoyed one of our best Christmases ever and hope yours were good as well.

The politics of health care reform have changed and the proposal I will put forward in this post seems to me to be possible if not likely.  The Republicans have taken themselves out of the picture.  They will oppose and delay.  The Democrats have the votes to pass at least the Senate bill.  The question is can they pass something better?  That, in turn, depends on whether each of the troublesome Democrat votes: Lieberman, Nelson of Nebraska, Landrieu, and a couple of other can kill anything at this point.  So my question is whether they might accept a small public option demonstration proposal?  The one I propose below is about as strong as might be swallowed.  It could be weakened in several ways and still be helpful.  If it can’t be done in the current legislation, it might be passed next year in a separate bill and get into the big reform after all.  If you like this post I hope you will forward it to your representative with your own comment attached.

PROPOSAL FOR A THREE STATE PUBLIC OPTION DEMONSTRATION

There has been speculation about whether or not a public option insurance plan would reduce costs by competing in the open market with private health insurance plans, whether a public insurance plan would have an unfair competitive advantage and displace private insurance plans, whether a public plan would increase coverage by attracting participation from people that private plans try to avoid.  These and other questions could be answered by research oriented tests of public option alternatives.

My proposal suggests a competition among interested states to run a demonstration public option plan.  I suggest that one state should be a small rural state with a dispersed population such as North Dakota, that one should be a state with at least one Major Urban Center such as Pennsylvania, and that one should be a state that proposes to focus attention on a particularly vulnerable population such as homeless women or injured workers needing rehabilitation.  Each application would be required to include a research proposal to be operated jointly by a leading medical school and a major University public health program.

To be considered for being selected a state proposal would have to be approved by a state legislature and governor.  Additionally, the state would have to agree to fund 20 percent of the costs of the research component of the plan. The selection of the three states would be completed by December 1st, 2012, with implementation to begin in January, 2013.  That makes the plan vulnerable to two congressional elections.

Federal and state funding requirements would be modest because a requirement of each demonstration would be that the provision of benefits and the cost of administering the plan would be met by premium payments plus the same subsidy supports that are available to those enrolling in private plans.  One demonstration might even save a state money by offering a voluntary alternative to Medicaid.  There would be three primary costs: financial support for thorough research with follow-up studies extending for a decade, planning costs, and initial capitalization.

Interested states could have until January 2011 to apply for a planning grant of five million dollars based on a commitment to offer a competitive bid to be selected as a demonstration state by November 1, 2012.  The selection of the demonstration states would be made by a three person committee that would include the Secretary of the Department of Health and Human Services, the Director of the National Institutes of Health, and the Surgeon General of the United States.  Each of the three named entities would be given five million dollars to monitor the process and prepare for the decision making.

An additional ten million dollars should be provided for an independent research study of the demonstrations to be constructed and operated by a committee of state insurance executives.

An additional ten million dollars should be provided to a major university to compare the demonstration plans in the three states to other state initiatives aimed at expanding health insurance coverage, as well as to the overall impact of health care reform legislation on existing state initiatives to expand coverage.
There are competing ideas about what should be included in a public option insurance plan and how such plans should be structured.  One criteria for choosing among competing proposals would be enhancing research of diversity in public option plan designs.  A second criteria should include the strength and commitments of the research component of each plan.  A third criteria should be the diversity of populations  of the states served by the three plans.  This third criteria extends the intent of the requirement that one plan should be in a small rural state and another in a state with a large urban population to maximize other diversity concerns that are important to the provision of health care such as age, race, cost differentials in the provision of health care, health care infrastructure, etc.
Funds sufficient to support the research components of this proposals should be authorized in the implementing legislation and followup appropriations should establish a separate trust fund to be administered by the National Institute of Health to support and provide accountability for the research activities.

Who needs sitcoms or The Daily Show?  The Republicans can supply all the laughs we can stand by themselves.

The St. Petersburg Times just awarded the Pants on Fire Biggest Lie of the Year Award to Sarah Palin for her promotion of the Death Panel story.  Bad enough that it proved a distraction from serious health care conversation.  Bad enough that it stokes alienation from government in general.  This lie and the follow-on chatter turned people away from, rather than toward, the need for serious conversation about end of life decision making.  There are many spiritual and relational factors to consider as life draws to a close, starting with compassion for the people whose turn for the intimate encounter with death.  Our compassion often extends to their families, friends, and caregivers as well.  A Christian concern for stewardship should also lead us into conversations about the expenditures of lots of money, our own money and the money of others, to extend life when life is painful and of little value to anyone starting with the challenged person.  For any of you who are outraged by this biggest lie of the year, I suggest that you use the Five Questions material to think through your own end-of-life choices.  A next step would be to make sure there are plenty of hospice services in your area that include well trained chaplains.  A third step would be to make sure that Doctors and other relevant professionals who should be part of such conversations get paid for this part of their work.

I smiled all the way home last night after listening to John McCain complain about lack of bipartisanship in health care reform, and about lack of transparency in the health care process.  He said something like, “Only one senator knows what is in the Managers Amendment.”  Gosh, all these months of intense debate, hearings, trial balloons, analyses by the Congressional Budget Office, and McCain doesn’t know what is going on.  Blaming your own ignorance on others in the midst of an informational blizzard could be taken as willful stupidity, but in my generosity, I prefer to ascribe it to a hitherto unobserved comedic streak in McCain and his cohort.  But what really makes all this so funny is that the Republicans haven’t cared a whit about what is in the health care reform bill.  They are opposing it, whatever “it” is, because if the Democrats pass health care reform, and especially if they pass good health care reform, the generational decline of the Republican Party is going to accelerate.  Political self-interest is understandable and appropriate.  It becomes funny at the point that it leads people, in this case Republicans, to follow the Art Linkletter scenario and “say the darndest things.”

Another transparently funny Republican tactic is to claim one ideology and then repeatedly act against it.  What is more core to Republican ideology than cutting waste and abuse in government spending?  At every turn, sometimes within a single paragraph, Republicans have claimed that the Democrat plan was too expensive while opposing every part of the plan that would cut costs.  Waste in Medicare.  Complain about cutting Medicare benefits.  Unseemly profits of drug companies?  Don’t allow the government to negotiate reductions, except maybe for military veterans.  Unseemly profits in private insurance companies?  Oppose a public option funded solely by premiums that would create competition.  What is more core to Republican ideology than a militaristic version of patriotism?  Now they are threatening to filibuster the Defense Spending bill they support to delay the health care key votes.  All these desperate delaying tactics and then they try to blame the Democrats for keeping the Senate in session through Christmas Day if necessary.

As Santa Claus would say, “Ho, Ho, Ho.”

Perhaps the most important clarification in the Obama speech at West Point is that the U.S. counter-insurgency efforts will focus on the Southern provinces of Afghanistan.  The Southern focus makes sense because most of the rest of Afghanistan already has something like counter insurgency underway under the leadership of other nations, mostly NATO allies.  By the count of a United Nations authority, there are coordinated redevelopment programs underway in 25 of 34 provinces, including mixes of economic and political development, often with a focus on building a trustworthy police force and judicial system.

The Pashtun tribes make up the largest minority in Afghanistan and have tended to dominate Afghani politics and control.  Both President Karzai and the Taliban are Pashtun centered.  The U.S. counter insurgency focus on the Southern provinces is mostly a focus on Pashtun tribes.  It is good news for the long range future of Afghanistan that the multiple minorities that are not Pashtun: Tajik, Turkmen, Uzbek, Hazara, and more, are mostly peaceful, and are mostly getting some redevelopment.  Because the central government of Afghanistan is so weak, many of the provinces are dominated by different minorities and province by province redevelopment is underway led by the United Nations with support primarily from NATO countries.

The U.S. has had the lead since 2001 in the Eastern provinces, half a dozen provinces along the border with North and South Waziristan provinces of Pakistan where Al Queda is focused as well as the leadership of several Taliban factions.  One additional combat brigade goes to the Eastern provinces, roughly 5,000 soldiers, and that should be enough to shut down Taliban activity and escape routes from Pakistan.  The strategy in that arena is not counter insurgency but counter terrorism, basically a military squeeze between U.S. and Pakistani forces.  Recently Pakistan pretty much cleared South Waziristan.  In most of the Eastern provinces there is not much opportunity for economic development because of the terrain and climate, though there might be mineral deposits somewhere.

Which brings us to the counter insurgency focus on the Southern provinces.  Three of the Southern provinces have Southern borders with the Balochistan province of Pakistan and that matters.  Balochistan comprises almost half of the land area of Pakistan, and is roughly the size of California.  It comprises about 5 percent of the population of Pakistan, depending on the groups doing the estimating and depending on whether you count a shifting number of Afghan refugees.  The great majority of the Balochistan land area is populated by dispersed Balochi tribes, plus a small tribe of Pakistani Kurds.

The Capitol of Balochistan is Quetta, the only city in Balochistan, with a population of around 750,000 people.  Quetta is a few miles South of the Afghan border, about 70 miles South of Kandahar City in Kandahar Province.  The border region, including Quetta, is dominated by Pashtuns.  Quetta has a strong network of roads and railroads, including a railroad to Kandahar City.  The Quetta border area plus Helmand and Kandahar provinces were a united, or at least cooperative unity, before British partitioning in the 19th Century.  The Pashtun economy in the Southern provinces, based on heroin and opium, includes Quetta.  Pressure on the Taliban in Afghanistan will likely lead to retreat into the Quetta area.  A huge question is what Pakistan will do in the Quetta area.  The Pakistani Army has a base in Quetta but most of its attention has been focused in the North and South Waziristan areas, and it is reasonable to guess that a substantial amount of drug trafficking money ends up in Pakistani hands, including bribes of Pakistani officials.

The surge is probably sufficient for clearing the Southern provinces of Taliban.  The holding and then the rebuilding phases of counter insurgency will depend a  lot on what happens in the Quetta region of Balochistan in Pakistan.  One important sign is that the Obama Administration is negotiating with the Pakistan governement and intelligence agency to start Predator drone attacks into Balochistan.  Another important political question is the relationship of the Pashtun to the Balochi tribes that control the big land area of Balochistan but not their capitol city.  The Balochi are also players, with their own tribal interests, in the drug trade.
Helmand and Kandahar provinces and the Quetta area are all dominated by river valleys with extensive irrigation of valley land.  In Helmand Province a lot of the irrigation systems was built with U.S. aid in the 1960s before the period of Russian occupation.  All three river valleys have major roads paralleling the rivers and there is a major hydroelectric dam on the Helmand river at the border with Kandahar province.  The major highway make a great West-East loop through the middle of Helmand and Kandahar provinces, then South to Quetta, then East, crossing the border into Iran, then North and back into Afghanistan through Nimruz Province.  Primary control of the Southern region boils down to control of Helmand river valley, the Arghandab River valley in Kandahar Province; the major highway plus the roads along the river, and the Khajak hydroelectric dam.  Almost all the towns and villages in both provinces are along the rivers and the economy is nearly all agricultural, recently mostly poppy growing to make opium and heroin.
Now for a quick introduction to the other Southern provinces.

Nimruz province is West of Helmand province and is mostly the Dashti Margo Desert.  It is a large province in land area and is the most sparsely settled province in Afghanistan.  Nimruz Province has a 60 percent Baloch population and less than 30 percent Pashtun population.  There is just one significant town, Zaranj, that has a population of about 45,000 out of a total provincial population of 120,000.  The town is on the Iranian border whee the major ring highway enters Afghanistan.  There is little or no poppy growing in Nimruz.  The Western border with Iran, as for Farah and Herat provinces to its North, provide a very different political situation than the Southern border with Pakistan.  Iran doesn’t like the Taliban for religious and political reasons.

East of Kandahar Province are Zabol and then Paktika  provinces.  Both border Pakistan and Paktika province could also be described as the most Southern of the Eastern provinces of Afghanistan.  There has been heavy fighting against the Taliban in both provinces as well as in Ghazni Province immediately to their North.  The Major East-West highway through Helmand and Kandahar provinces is also part of a major loop highway that branches North through Zabol and Ghazni provinces between the mountain along the Eastern border with Pakistan and the central mountains of Afghanistan.  The highway goes up to Kabul, the capitol, then swings west around the central mountains to Herat and then back South again.  All three provinces are arid and without river valleys and therefore limited agriculture.

Paktika Province is heavily Pashtun.  Zabul and Ghazni provinces are ethnically mixed with significant variation between districts.  Ghazni City is a regional trading area about half way between Kandahar City and Kabul.  All three provinces have little development due to a lot of arid and mountainous areas.  There is some opportunity for political development and improved services, but economic development looks hard to me from this long distance.  The main point about these three provinces is that they represent likely areas for retreat by the Taliban when pressures grows on Kandahar and Helmand provinces.  Tribal dynamics will be important for the “hold” phase (second phase) of counter insurgency.

From 2006-2008 the military situation in the Southern provinces was been roughly at a standstill.  Some towns are ghost towns and there are a lot of refugees.  Starting in 2008, with significant escalation in 2009 because of the introduction of 30,000 or so U.S. troops, the clearing phase of counter insurgency is well under way.  A lot of the towns along the river valleys that were Taliban held, fought over repeatedly, are devastated but are now in U.S. hands.  Additional troops can finish the clearing phase and pursue withdrawing Taliban in Zabul, Paktika, and Ghazni provinces.  This means that U. S. forces can control what is grown in the river valleys and cut off a major source of funding to the Taliban.  That, in turn, will weaken the Taliban ability to hire fighters and makes “Taliban reintegration” more likely to find success.  Counter insurgency in 2010 will hopefully move more into second and third phase activities: agricultural transformation, the rebuilding of towns and infrastructure, the resettlement of refugees, and the crucial work of developing local self-government not dominated by either the Taliban or the drug lords.  The last part gets into critical tribal politics, both within major tribes and between tribes.  Some major tribes, including anti-Taliban tribes, are going to be unhappy about losing drug income and smuggling incomes, and that will be a major challenge.

In addition to what goes on in Afghanistan, I hope these blog posts have provided some context for appreciating the huge importance of Obama’s announced intent to gain a much better integrated working relationship with Pakistan.  There are a lot of Pashtun in Pakistan and some are either friends with Taliban or drug smugglers.  For me, the major measuring rod will probably be what Pakistan does in the Quetta region of Balochistan.

I hope you, my faithful blog readers, felt prepared to evaluate the Obama speech on Afghanistan.  I invite comments on the speech in general as well as your response to this post using the comment button below.  In addition to listening to Obama’s speech, I was also helped by backup news stories in the New York Times and particularly the Washington Post.  I’ll probably pick up on some items in more detail in a later post, but here are my first level reactions to the speech.

The speech was pretty much what I expected. except for the unexpected clarity of the time table to begin withdrawal.  On the withdrawal, it is worth noting the care with which Obama has been withdrawing troop from Iraq.  I was a little surprised that he announced a tight timetable for pulling all combat troops from Iraq by next Summer.  That contradicts some news reports I had read and passed along in recent blog posts. This correction is good news on the cost of war front, on the troop exhaustion and morale levels, on the ability of military leadership to focus on Afghanistan, and on the general remaking of the U. S. Army around counter insurgency and small unit strategies.  It validates my original projection that the effort on Afghanistan should be affordable.

You may find it helpful to note that the projected “surge” of 30,000 more U. S. combat troops in 2010, is smaller than the increase, not called a “surge,” of about 40,000 combat troops in 2009.   And, based on my reading of the 2009 Defense Authorization Bill, Obama is correct that about one-third of the surge has already been authorized by Congress.  It is also interesting to me that the United States has the airlift capacity to move the troops and supplies so quickly.  Some supplies will move by ship, but Afghanistan is a land-locked country.  No other nation has even a major fraction of our airlift capacity, an expensively purchased airlift capacity supported by an expensive mid-air refueling capacity.  If nothing else, the capacity to carry out this maneuver is a clear demonstration of the U.S. ability to continue the gift of Pax Americana to the world.  Maybe I’ll get around to what I mean by Pax Americana, the good and the bad, in a post before too long.

Did you catch the two subdued signals about the change in toleration of the opium and heroin trade?  Obama did make a passing reference to opposing the drug trade, easily missed and hardly emphasized.  The important signal to me is that Obama said the United States would focus economic support on agriculture in the Southern provinces, read a focus on Helmand and Kandahar provinces.  I think, and I hope, that means an end to poppy growing in those two provinces.  That is achievable and the farmers, at least, can come out of it happy.  We can buy off some of the drug lords, drug traffickers, by enlisting them and paying them to fight the Taliban.  Watching how the effects ripple out to the “quiet” provinces and “friendly” stans is going to be extremely interesting to me.  And what new group of farmers will start growing poppies to meet the demand?

Though I tend to automatically and cynically take rhetoric about the “moral source of America’s (sic) authority” with a truckload of salt, I did notice that it is pretty hard to make a case that Afghanistan is part of empire building for the United States.  There is very little we want or could use from Afghanistan.  We have already won the Cold War.  In contrast to Iraq, where I do indeed believe that a major motive of the W Administration was the “national interest” of big oil and multinational corporations generally, a la Cheney and pals, the multinationals have very little presence in the economic development of Afghanistan.  In dramatic contrast to Iraq, most economic redevelopment is being done by Afghanis and is a major source of emplyment in a very poor country.

Will it work?  To start with, the “it” shifted a bit in this speech.  Obama narrowed and limited our goals.  There was no soaring rhetoric like the Neocon blather about democracy that was no more than a magicians cape for exploitation by multinationals.

The Washington Post backup story says that we have already deployed 36,500 troops to the Southern provinces.  That accounts for where the 2009 buildup has mostly gone.  With 9,000 British troops in Helmand Province already, we have an impressive force in the key provinces.  The withdrawal of 2,300 Canadien troops from Kandhar Province has already been made up and them some.  With most of the surge going to the Southern provinces it seems to me that the U.S. has the resources for dominance.  I expect most of the Taliban leaders to flee.  Mullah Omar, the top Taliban faction leader already operates out of Pakistan and Pakistani leaders have reason to worry about an influx of Taliban.  On the other hand, Pakistan is already dominant in South Waziristan.  Iran is hostile to the Taliban, and the Baluchistan area of Pakistan is pretty isolated and arid.  Maybe, even hopefully, a major transformation can be accomplished in 18 months and some withdrawal of forces will become realistic.

Would you like to understand the costs of sending an additional 34,000 combat troops to Afghanistan?  So would I.  What you will get in this post is context for understanding the questions involved and a few referent numbers that provide some landmarks.

The Obama Administration is using a figure of one million dollars per combat soldier per year for troops deployed to Afghanistan.  The Pentagon says the cost is about half that much and that ANY such number is highly speculative.  I don’t think this kind of variability is intentional or intrinsically misleading.  I think it is all about what is being counted.

There are three distinct kinds of numbers for counting troops.  The first number is combat troops.  The Obama plan is to send an additional 34,000 combat troops to Afghanistan starting with an 8,000 increase in January, 2010.  The remaining 26,000 troops will be deployed based on circumstances that can affect timing.  Those circumstances include deployment options by the U.S. and developments within Afghanistan.  The 8,000 additional troops will go to the Southern provinces, probably with a focus on Helmand province.  (See previous posts for the significance of targeting Helmand and Kandahar provinces.)  This is the most reported and perhaps the most understandable number.  However, we have the question of additional to what.  In 2009 the level of combat troops has already increased from about 30,000 to about 62,000 with another 6,000 expected to be added by the end of the year.  The calander year is not the same as the fiscal year and the Congress works out of fiscal year counting.  For the sake of this post I’m going to assume that combat troops in Afghanistan will increase to 100,000 combat troops by the end of calander year and fiscal year 2010, and I consided the variability in estimating the resulting financial costs to be in the tens of billions of dollars.

The Pentagon reports to Congress are counted in terms of “boots on the ground.”  I take that to mean roughly the same as “combat troops” but I am not comfortable with my assumption in this regard.  “Fortunately” such grumbling over terms is swept away by the third set of numbers which count “total troops.”  The Administration and the Pentagon ar not giving us much information about total troops.  The best I can estimate is that when the Administration uses the one million dollars per combat soldier figure it is counting in the costs of logistical support and that would include the costs of support troops.

Another consideration is the counting of military contractors.  They are a big part of the Iraq war costs.  Are they as important in Afghanistan?  Maybe or maybe not.  This number gets swallowed up in the bigger unreported number associated with the economic development and political development and military training costs.  Some of that work and costs is done by combat troops.  Hopefully, in the new emphasis on counter-insurgency strategy, most of the economic and political development will be done by specialists and not by combat troops.  I’m thinking that the development and training aspects of counter-insurgency could easily be more than the costs of the combat troop surge starting in 2010.

Another unknown category of spending is the “black budget” part of military spending.  Spending for the CIA and other intelligence efforts comes out of this unreported part of the budget.  The CIA has been important in operating the drone Predator planes and also in cutting deals with various Afghan leaders.  This might not be a lot of money compared to combat troop or all troop budgets, but we don’t know and wont know.

Take all this together and the number of one million dollars per combat soldier per year may be a very reasonable figure and that reasonable figure could be merely a significant part of the total costs of expanding into counter insurgency in Afghanistan.  One of the things I am going to watch for is whether we expand counter-insurgency only in the Southern provinces or also expand in the Eastern provinces where our primary commitment of troops has focused prior to 2009, or perhaps into lots of the other 34 provinces where some international development work is already under way, a whole lot of development in some provinces like Herat Province.

Another thing I will watch is how we move into Kandahar province, the other big obvious target in Southern Iraq.  The Canadiens have taken the lead in Kandahar Province and they are currently pulling out.  We will be woring with 9,000 plus British troops in Helmand and will be largely on our own in Kandahar.  Both provinces are excellent targets for counter-insurgency techniques while many of the Eastern provinces are so mountainous and remote that it is hard to see what realistic economic development is feasible.

In the face of so many “known unknowns” I found some solace in putting the Afghanistan effort in the context of the total U.S. military efforts and expenditures.  At the end of Fiscal Year 2009 (October, 2009) the United States had about 1,368,000 military personnel of whom 726,400 were in the Army or the Marine Corps.  That was an overall decrease in military personnel from FY 2008 because the 12,000 increase in the Army and Marines was offset by a decrease of 16,600 in the Navy and Air Force.  An additional 25,000 Army and Marines were approved by Contress in 2009 for Fiscal Year 2010.  This means the total Army and Marines soldiers will be expanded by about the same size as the surge.  Will that be offset, or partly offset, by further decreases in the Navy and Air Force?

The base military budget for the Department of Defense for Fiscal Year 2009 was $518.3 billion dollars.  When I do the long division that comes out to $373 thousand dollars per military person in the Army, Navy, Marines, and Air Force.  Currently, about 200,000 military people are on active duty in Iraq and Afghanistan.  Our total military base budget cost per current active combat soldier in Iraq is about 2.9 million dollars.  That is $2.9 million dollars before counting the costs of deployment.  Of course we are spending for a lot of military purposes beyond the wars in Iraq and Afghanistan.  But the two wars are the dominant focus of the Army and Marine Corps.  The Army and Marines account for more than half of the uniformed military personnel, but again for rough estimation purposes for this post, it is reasonable to estimate that it costs $1.4 million dollars per deployed combat soldier per year without counting deployment costs.
In 2009 Congress passed a supplemental military spending bill of $130 Billion to fund the war efforts in Iraq and Afghanistan.  There is reported talk in the Pentagon about asking for an additional $50 billion for FY 2010.  It is certainly not a hard number but, for the sake of this blog, let us assume that with the surge in Afghanistan the additional cost beyond the base budget for fighting the wars in Iraq and Afghanistan is $180 billion dollars in 2010.  That works out to $900 thousand for each of the 200,000 combat troops for 2010.  Add that to the base budget cost and you get $2.3 million per combat soldier for 2010.  Perhaps the more relevant number is that $900,000 is pretty close to the Obama Administration $1 million per soldier per year.  Considering that more than half our combat troops will be in Iraq in 2010 where that war is winding down, $1 million per combatant seems about right as a referent number.  Thus it costs roughly three times as much to support a soldier in combat as it does to hold a soldier in reserve in the Untied Staes.

All of this context brings me back to the number I used in a previous post on Afghanistan.  I said that the U.S. could easily afford the war in Afghanistan because we were pulling out of Iraq.  That seemed obvious to me.  At that point the core numbers I was working with were 130,000 troops in Iraq and an increase to 100,000 troops in Afghanistan.  What I wasn’t counting on was very little draw down of total U.S. troops in Iraq in 2010.  I’ve read some Pentagon referenced stories that claim we will not be significantly drawing down troops in Iraq in 2010 and I have no independent grounding for denying such stories, but they don’t make sense to me.  It is appropriate from my perspective that Obama is being careful about withdrawing forces in Iraq but there have been numerous stories about changed missions, preparations for withdrawal, the trasfer of various assets to Afghanistan already, etc.  Troops are scheduled to rotate out of Afghanistan in 2010 so all that is needed is not replacing the troops returning home, or replacing them at a small fraction of current strength.  In any case, stated policy is to have all the troops out of Iraq by the end of 2011.  That means to me that we would have about half as many deployed troops at the end of 2011 as we have today.  That, in turn means to me that we are facing a one year, maybe two year, funding crunch, in terms of supplemental military spending.  Considering all we have already been through and the investments of treasure and blood already made, getting through 2010 seems like a very reasonable and politically achievable goal.

I’ll join you in assessing the meaning of what President Obama says to us tonight.

This post is the fourth in a series on Afghanistan.  To understand this post I suggest that you read my previous post by scrolling down if you have not read it already.

A key strategic question that is proving difficult to estimate, let alone answer, is whether Afghanistan can become a functioning nation on its own if NATO military strategies are successful.  If the answer is no then counter-insurgency is a dead issue and the remaining alternatives are all unpleasant to contemplate.

I certainly do not have the magical answer to the viability question but this post will try to put the question in perspective.

Counter-insurgency is already underway in numerous provinces and can be improved in all of the 34 provinces in Afghanistan.  The focus of the proposed increase in counter-insurgency with a surge of combat troops backed up by a surge in economic and political development, however, is focused on Kandahar and Helmand provinces, and two or three neighboring provinces.  These provinces are on the Southern border of Afghanistan with the Baluchistan area of Pakistan across the border.  Canada currently has the lead in Kandahar Province with 2300 troops and Britain has the lead in Helmand Province with 9000 troops.  The U.S. has some troops in both provinces and has been active in some of the heaviest fighting.  General McCrystal apparently wants about 10,000 additional combat troops for directly fighting the Taliban faction under the leadership of Mullah Omar in these provinces.  Omar was the top leader in Afghanistan after the Taliban seized control following the defeat of the Soviets.

10,000 additional U. S. combat troops would roughly double the fighting potential of NATO forces in the two provinces and let’s assume, for the sake of developing context, that this is enough troops to radically degrade Taliban military capacity.  The recent success of the Pakistani Army in South Waziristan support such an assumption.  It is already the case that the Taliban cannot win any large scale actions because the U.S., Canada, and Britain, control the skies.  The most effective things they can do is lay land mines, use suicide bombers, and mount small scale raids and murders.  The counter-insurgency strategy turns on creating enough security for the important part: economic redevelopment and the creation of respected local government.  Counter insurgency does not  require a strong and effective national government if local reform is strong.  Then, as currently in Iraq, the process of creating an acceptable national government becomes possible, if hardly assured.  Well, that’s the theory.

So why is corruption so important?  After all, since the 1950s, the primary way the U. S. has been involved in the Middle East, including the “stans,” has been through CIA corruption and manipulation of various minorities.  That corruption including cooperating with Pakistan to create the Taliban to help fight the Soviet invasion.  It was very successful corruption except that the Taliban kept right on going after the United States pulled out.  Equally or more important, during the Cold War against the Soviet Union the United States, via the CIA, was also busily involved in corrupting the warlords of the Northern Alliance and their patron countries across the Northern borders, the Uzbeks and Uzbekistan, the Tajiks and Tajikistan, etc.  Think of CIA operatives slinking around with bags full of cash.  When we do such things we call it making deals.  When “they” do such things we call it corruption.
The big problem we face today is that the primary mechanism for corrupting the “stans” was State Department and CIA support for the poppy/opium trade going back as far as the 1950s.  That corruption included both direct support, like flying opium out in CIA planes, and indirect support by making sure no one disrupted CIA contacts and leverage with the warlonds and the stans.  This indirect support has continued to this day, always out of the light of day.  The U. S. would now like to break the poppy/opium trade up because it is a major source of financing to the Taliban.  Progress has been made in a few provinces according to a United Nations report, but not in Kandahar and Helmand provinces, the heartland of support for the Omar faction of the Taliban.  These two provinces produce 80 percent of Afghan opium and heroin, and Afganistan provides about 90 percent of the world supply of opium and heroin.
At first I thought, how hard can this be.  Certainly we could buy off poppy farmers a lot cheaper than we can run a big military effort.  And so we could.  The opium trade is hugely lucrative but the poppy farmers are not highly paid.  A lot of farmers in a lot of settings receive a small share of the total price of a product.  Buying off the farmers, preferably by heavily subsidizing a transition to other crops, is a reasonable and achievable element of a counter-insurgency strategy.  But then there is corruption.

To understand the corruption problem we need to start with the scale of the opium business.  According to the U.N. Office of Drugs and Crime, Afghanistan exports 900 tons of opium and 375 tons of opium a year.  Considering that one ounce of opium call sell in London for $100 you quickly get the picture that a lot of money is going to those who market, distribute, transport, and provide security for the business with a lot left over for “bribery and corruption” at every step along the way.  A lot of that way is North through all the “stans” and on to Indian and China, to Russia and Central Europe, and finally to Western Europe and Britain.  The United States only uses about 20 tons of heroin a year and gets most of its supply from Central and South America.

Lets look a little more closely at who gets most of the money.  A nice window on this process is opened in an article called “The Master of Spin Boldak” in the December 2009 edition of Harpers Magazine and is currently available at newstands.  A significant part of the money goes to the “traffickers” and a significant amount goes in bribes at every stage of the journey across a mammoth land area.  The first stages of traffic are either across the border into the Baluchistan area of Pakistan or North through the “quiet provinces” of Afghanistan.  If the U. S. stops the poppy production, and we already have the capacity to do a lot of that, we are going to make a lot of warlords unhappy in Afghanistan, the very warlords who are supporting NATO efforts against the Taliban.  The recent revelation that Hamid Karzai’s brother is big into the opium double-dealings, and has received significant bribes/payments from the United States, shows that it isn’t just warlords in the provinces who would be upset.  Then as you move into the “stans,” and the NATO military effort is dependent on bases in some of the “stans” for staging into Afghanistan, a lot of our current “friends,” the “friends” who have long been bribed directly and indirectly by the CIA, could become very unhappy, very quickly.
I have seen thereports that there is also a lot of corruption and inefficiency in our previous spending for economic redevelopment.  That matters too but it is just garden variety bribery and corruption and inefficiency that can be addressed by tightening up NATO relief and redevelopment efforts.  Thus the big problem in corruption, the publicly little-discussed problem of corruption, the problem that I’m guessing is causing a lot of the distress in current decision making, the big problem in the proposed increase in counter-insurgency in Kandahar and Helmand provinces, is not failure but success.
Please do not carry this conversation forward in a partisan tone.  Democrats and Republicans, Administrations and Congresses, are all up to their arm pits, if not to their lower lips, in this cess pool of “real politics.”  The task of trying to clean up this mess is now in Obama’s lap, but the generation of the costs goes back to Henry Kissinger and John Foster Dulles and many more of our unsung foreign policy “heroes.”  It is too painful for public discussion by the Obama Administration and even the best of our media are still writing around the edges.  The best single source I found was a recent report by the United Nations Office for Crime and Drugs.
One of the things that bothers me most as a Christian is that the 15 million addicts that consume the Afghan opium and heroin are mostly far away and out of sight.  The damage is mostly happening outside the United States.  We play our manipulative foreign policy games and get the benefit of winning the Cold War.  The United States has paid bribes but mostly done our dirty work “off the books” by supporting the trafficking of opium and heroin.  The big prices have been paid in those other countries we don’t care much about, the ones that are hard to remember from any classes we took in world geography.  One way I understand our dilemma is that we are finally having to deal with God’s judgement on our collective sins.  I understand that some good things came out of those decades of CIA manipulation, but all the cover-ups are unraveling.  At least President Obama apparently has the courage to look into the dark corners that have now become so inconvenient.

I don’t know what to do and nobody in power cares what I think anyway.  I do know how to pray and right now I’m finding it hard to stop praying and get on with other parts of my life.

Previous posts have addressed the theory of counter-insurgency as it applies to U.S. efforts and plans in Afghanistan as those plans relate to the Christian Just Peace tradition and argued for Christian based support of the proposed expansion of combat troops in that country.  This post puts the decisions to be made in the context of what is actually going on.  (I plan to address the most difficult question facing Obama, but little talked about, in my next post: corruption and the opium trade.)  I begin this post with several questions so you can test your own knowledge of some key facts, a proxy for the adequacy of the media reports we have been getting.

1. As of October, 2009 there are about 67,000 troop in Afghanistan from NATO and oher participating countries.  What percentage of these troops are U.S. troops.)  (Hint: the October 2009 number includes the 16,000 plus troops that have been added by President Obama so far.)

2. Where have U.S. troops been primarily deployed and carried lead responsibility?

a. Guarding Kabul and supporting and protecting the government of Karzai.

b. In the Western provinces bordering Iran to fight the Taliban and to block infiltration and smuggling, etc.

c. In the Eastern provinces bordering Pakistan with a focus on fighting Al Queda and generally securing the border.

d. In the Central and North provinces working with Tajiks, Uzbeks, Hazara, and Turkmen who together make up the majority of the population of Afghanistan.

e. In the South, particularly in Helmand and Kandahar provinces fighting the Taliban and suppressing opium production.

3. Herat province is in the West and borers Iran.  Herat city has a population of 400,000, a university with 12,000 students, a 3,000 year history as a major cultural center in that region, and the majority of the population speaks Farsi and is Shiite Muslim like its neighbor Iran.Which of the following statements is true?

a. Herat has been a center of unrest, weapons smuggling, and anti-Karzai political activity.

b. Herat has seen significant fighting against the Taliban and only overcame the Taliban in 2007.

c. Herat is being helped in redevelopment by non-governmental organizations representing over 60 nations and 40 international organizations, with little U.S. involvement.

d. Spain, New Zealand, and Romania, have taken the lead in various parts of Herat Province.

4. Which three nations have carried the brunt of fighting the Taliban and al Queda and have suffered the highest casualties?

Answers will be provided below.

One thing to remember about Afghanistan is that the Taliban primarily appeal to the Pashtun ethnic group which represents 38 percent of the total population.  Hamid Karzai, the president, is aso Pashtun and his political base is Pashtun.

There are 34 provinces in Afghanistan and 25 of them have Provincial Development Teams.  Only a few of the PRTs are led by the United States.  Some PRTs face heavy raiding by the Taliban or Queda and many do not.  Perhaps a third of Afghani provinces are fairly remote and are mostly being ignored by all concerned.

Afghanistan is mostly Sunni Muslim in religious faith and comparatively little of Afghanistan is attached to Wahabi Islam, usually considered the fundamentalist kind of Islam favored by the Taliban.

Here are the answers to the questions.

1. Slightly more than half of the troops in Afghanistan are U.S., about 34,000.  The additions under Obama have almost doubled the size of the U. S. force and the request by General McCrystal would more than double it again.

2. The United States has concentrated its efforts in the Eastern provinces bordering Pakistan and have been primarily focused on counter-terrorism activities against Al Queda and more recently also on the Haqqani wing of the Taliban.  This focus began with the unsuccessful effort to capture Osama bin Laden.

3. Herat has been relatively peaceful and has had economic development from 100 plus national and international NGOs.  The Taliban has raided there but not established a presence there.

4. Britain, Canada, and the United States have done most of the fighting and taken most of the casualties.  In the two major provinces which have gotten most of the press attention, Helmand and Kandahar, the U.S. had a minority presence but an active military involvement.  In Kandahar Canada has had the lead with 2,300 soldiers and taken most of the casualties.  The U.S. has about 1,000 troops in Kandahar.  In Helmand Province, Britain has had the lead and has taken the most casualties.  Britain has approximately 9,000 troops in Helmand Province.  A significant part of the troop buildup that General McCrystal has asked for would go to strengthening U. S. involvement in these two provinces.

These facts give me, and I hope you, a bit more appreciation of why President Obama is taking his time to think through proper policy in Afghanistan.  Following are a few comments that will guide my assessment of his choices.

1. Because on support from NATO countries, the United States does not have to construct an all-Afghanistan strategy.  This is a gigantic difference from Iraq where we had Britain’s help in far Southern Iraq and small contributions elsewhere.  For example, in Afghanistan Turkey has primary responsibility for the military defense of Kabul, the Capitol, with about 750 troops.  The contrast to Iraq, where the U.S. has had to give so much attention to Baghdad, could hardly be more striking.

2. There is already a lot of counter-insurgency kind of activity going on in 25 of 34 provinces with fair continuity in many of these provinces and at least 5 to 6 years of experience, mostly led by other countries.  It has led to significant infrastructure improvements, including such things as more schools for girls and women.  Some trust has been won in many provinces.  Most of the actual work is being done by Afghani workers, another big difference from Iraq.  Furthermore, the redevelopment is being led by NGOs rather than multinationals, another big difference from Iraq.  All of this suggests to me that counter-insurgency can work in other provinces if sufficient security can be established.  Furthermore, when the Taliban raids redevelopement projects and kills civilians with bombs in markets, etc., this does not make them look like good guys.

3. The U.S. presence in the Eastern provinces that have borders with North and South Waziristan in Pakistan is about 20,000 troops.  Think of the border as being roughly the size of the U.S. East Coast from Maryland to Maine.  A lot of the area is rugged and mountainous without much in the way of roads and infrastructure.  It isn’t so easy to think up useful economic redevelopment in these conditions.  There is plenty to be done in roads, schools, and clinics; but that is not likely to translate into peace and prosperity in a hurry.  In short, troops are needed for counter-terrorism in the East and counter-insurgency tactics will need to focus on improving the status quo, supporting local leaders, and distinguishing local fighters who are trying to protect their turf from Taliban and Queda infiltrators.

4. There are four or five Southern provinces where the Taliban is strong.  One, Nimroz, is mostly desert and has a strong majority Balochi population.  (This part of the border with Pakistan is the region of Balochistan.)  The key to defeting the Taliban focusess on Helmand and Kandahar with secondary focus needed on two or three more neighboring provinces.  Apparently the highest priority of General McCrystal is to send 10,000 combat troop there as soon as possible.  These two provinces together, and Helmand in particular, are the Poppy growing provinces and produce between 80 percent of the Afghanistant total.  Afghanistan produces about 90 percent of the world supply of opium, but little of the opium consumed in the United States.  MOre on this subject in my next post.
5. I started into updating myself on Afghanistan with the sense of a clear distinction between al Queda and the Taliban.  My current view is that the Haqqani wing of the Taliban is pretty integrated with al Queda and is centered in North and South Waziristan provinces in Pakistan, and is the focus of the current Pakistani led fighting there.  This justifies some continuation of counter-terrorism strategies and highlights issues of cooperation and focus between the U.S., Afghanistan, and Pakistan.  The Taliban presence in Southern Afghanistan is led by Mullah Omar and seems to be much more focused on recapturing Afghanistan than on international issues.
6. It is very important to keep in mind that we have far less presence in Afghanistan than in Iraq.  As we pull out of Iraq over the next 2 years we will have significantly more military resources to use in Afghanistan while also rebuilding our general military strength.  I plan to address cost and sustainability in a future post to this blog and I will tip my hand that the press focus on the $1,000,000 per soldier, per year, number for expanding our effort in Afghanistan is misleading.  The main strategic question for me is not whether 40,000 combat troops is too many, but what is the time-table for relocation and refocus, and what is our strategy for non-combat troops and for anti-narcotics in Helmand and Kandahar.

October 26, 2009

This is Monday, the first day of the week of the big squeeze decisions in health care reform.  Actually, two big political processes are going on simultaneously.  On the one hand, the basic financial structure of health are reform will probably be decided this week, maybe next week, the big squeeze.  On the other hand, the big coalitions that got us to this point in pushing for health care reform in general are breaking apart as the focus switches to getting all you can for your particular interest in health care reform.  I mean both the economic self-interest of those who will receive money in the new reformed health payment systems and the common good interests that are focused on a specific disease, a specific sector of the population, a specific geographic area, etc.  What gets hidden, and what often drives the average citizen crazy, is that deals get cut on specifics to attract tipping votes on the general structure.

Here are the parameters of the big squeeze.  Everyone should be covered with a good health insurance policy.  Costs to the federal government, as scored by the Congressional Budget Office, should not increase.  I’ve already written a lot about how distracting it is to focus on CBO estimations that are treated as the proxy measure for cutting costs for health care.  That is a real big deal but it is not the functioning political measure for this week’s debate.  I’ve also written about various cost-saving projections that have been part of making it possible to put health care reform on the table in the first place.  Resistance to cost cutting by special interests, by labor unions that already have good insurance for their members, and by Republican trying to deny Obama and the Democrats a political victory, make the target for cost-neutral reform harder to reach.  However that target is worked out, the squeeze is that some more income or others savings will be needed to stay cost neutral.

The need for more savings has brought the public option back into play for two main reasons.  The first is that it would lead to cost-savings by providing competition to private insurance, particularly for individual or small group private insurance policies where the most outrageous private insurance practices occur.  The second point is that the public option can be structured so as to focus insurance availability for the 20 million people not covered by the Senate Finance bill.  For those of you who agree with me that a robust public option is important for health care reform, I suggest you focus your message on support of the state opt-out version that will let South Carolina, et al, express their alienation from the national government of the United States; and on opposition to the trigger-mechanism being floated by the Obama Administration as the best way to get the vote of Olympia Snowe.  Instead, give Snowe what she really wants: more federal subsidy for the purchase of private insurance.

Public option or not, more income is needed to get through this squeeze.  There are three main potential sources of income and all should be utilized to distribute the burden: a progressive income tax on individuals who earn more than $500,000 a year and on families that earn more than $1,000,000 a year, a recovery of part of the tax benefits currently given to big employers for health insurance that has often been negotiated with unions, and a mandate that all who get private or public option health care with federal subsidies pay an affordable part of the bill.  The last provision primarily affects employed young people who are currently healthy and have little financial reason not to accept bankruptcy as their insurance policy.  People who are young, healthy, and employed should buy health insurance in case they need it AND because this structure will support them, in turn, if they get sick or injured, when no longer young, or if they lose their job.  In short, we should pay for health care at the the times in our lives when we can afford it rather than when we can least afford it.

For those newly forced into buying insurance through mandates, and for those currently being ripped off by buying their insurance as individuals or in small groups, and for those who already have good insurance through an employer that is partly subsidized by tax breaks, it is very important to remember that health care reform should substantially lower premium costs because it will eliminate, or least greatly reduce, the current “hidden tax” of cost shifting by hospitals and other health care providers that is needed to balance off the costs of currently uncompensated care.  All the people who will newly get their health care costs paid for by Medicaid or by newly subsidized private insurance, about 48,000,000 million people, are paying their costs through Medicaid or the new insurance policies.  That means those costs will no longer be shifted to current private insurance.  Of course oversight and pressure will be needed to make sure that private insurance companies actually pass along these saving with reduced premiums and reduced cost sharing.

I close with a positive note.  I am very hopeful that all the current attention to the sharing of health care costs, costs we are already largely sharing in unfair and largely unnoticed ways, will lead to the big potentials for reducing costs: improved health and lowered need for services.  I’m talking about school lunches and breakfasts and physical education classes, a lot more attention to maternal health, healthier employment practices, bicycle paths, clean air, and more.  There is a lot more at stake than improved public and employer policies.  We can do so much more in the informality of culture.  We not only need to read to our children, we need to make sure they brush their teeth.  We can do immensely better to help people face end-of-life decisions with caring and understanding.  Think how terrific it would be if we could focus more public attention on health rather than health care.

The Christian perspective of Just Peace, developed by the United Church of Christ and now gaining increased adherence in mainline denominations, emphasizes constructive action for peace in addition to the Christian perspectives of pacifism or just war.  The just peace vision is about more than avoiding war, more than the rules for war once begun, more than about the agonizing decisions of individuals who face the choice of whether to fight and kill or not.  The “more than” is about acting justly and taking the moral high road in diplomacy, is about treating others with respect and caring even when they are opponents or enemies with the aim of turning enemies and opponents into friends, or at least into constructive competitors.  It is about looking for improvement of the common good rather than mere national or economic self-interest, and about building hope and trust to support processes to find a way to peace even when the snapshot of circumstances is dire or depressing.

My intention in my previous blog post on Afghanistan, and in this post, is to consider U.S. options in the light of just peace perspectives.  In the last post this led me to support sending of more troops to Afghanistan to support the counter-insurgency strategy of General McCrystal.  This put me at odds with most of my friends and colleagues in the anti-war movements of past decades.

As I have thought further about U.S. military involvement in Afghanistan I have gained confidence that counter insurgency strategies line up pretty well with a just peace perspective, and more confident that the United States should give counter-insurgency strategy a thorough chance in Afghanistan.  At the pragmatic level, the withdrawal of troops from Iraq makes adding troops to Afghanistan feasible while reducing the overall costs of our military involvments.  My reasoning follows.

The language of counter-insurgency sounds military and technical and it is easy to project that counter-insurgency is more of the same old militarism dressed in different clothes.  The language of Obama and the Pentagon that focuses on “redeploying combat troops” supports the assessment of same old militarism.  Neither has it helped to blame George W. Bush for the war in Afghanistan, though he certainly deserves a lot of blame for his handling of the war.  The justification for counter-insurgency has nothing to do with looking backward.  If we can get past old anger and regrets and blaming; if we can understand counter-insurgency in a just peace perspective, then I hope many of you, my readers, will transition to supporting the Obama Administration if it goes for the McCrystal counter-insurgency plan, as I predict they will.

The first premise of counter-insurgency is that there needs to be security at the local level to “give peace a chance.”  It takes more troops to do this work than it does to follow the losing “whack-a-mole” war-fighting strategy that focuses on killing enemies with aggressive patrolling, predator drone attacks, etc.  It takes a lot more to “give peace a chance” than to try to kill Osama bin Laden or the various Taliban and al Queda commanders.  Counter-insurgency is a local strategy that works with local leaders to achieve local goals.  U. S. combat troops provide the security with an emphasis on defensive patrolling and building up strong local intelligence that is timely and relevant.  It builds on the self-interest of local leaders to defend themselves against the Taliban, et al, and appeals to local families by engaging them in solutions to their problems that improve their life circumstances.  This builds morale and investment in peace.  It also involves training of local leaders and employment for local young men to handle the security problems themselves.  When they line up with U. S. forces they become enemies of the Taliban, whatever their religious or ideological perspectives.  It takes time to work through corruption and slippage, but that is a doable task if troops can hang-in long enough in a local area rather than chasing around after the bad guys.

Though there hasn’t been much discussion of the following point.  The success of counter-insurgency does not depend on combat troops.  Providing local security merely provides the context for the big work of counter-insurgency such as building schools and providing teachers, restarting the local economy, making sure that farmers can make a decent living selling wheat or olives rather than opium poppies, etc.  Instead of the disasterous neo-con strategy of Dick Cheney in Iraq that tried to turn the assets of the country over to multi-national corporations, counter-insurgency emphasizes support for local initiatives and the creation of non-corrupt local self-government.

Conservatives were brutal in their rhetorical attacks on “nation building,” but have now swallowed nearly the same thing as counter-insurgency, because they want to point to the good part of George W. Bush’s conduct of the Iraq war in his last years in office.  I regard George W. Bush as the worst president of the United Staes in my lifetime and have to constantly reminding myself not to let anger and resentment distract me from focusing on what can positively be done now.  The language of counter-insurgency, the positive contributions of counter-insurgency in Iraq, has kept conservatives on board and supportive of Obama and McCrystal, so we shouldn’t try to change the language.  We just need to understand it for what it is and work to make sure it is done right.  Keep your eye on the prize.  The purpose of combat troops in counter-insurgency is to make possible the various kinds of just peace activities that can be enabled when violence and surival overwhelm all other concerns.

Perhaps it will help to recast my point briefly as a change in choices for angry young men in Afghanistan.  When your national government is corrupt, distant, and incompetent; when foreign troops are running around killing people you know and care about; your choice is to fight for change with the Taliban, et al, or hide out while your known world goes to hell.  Counter-insurgency provides an addiional choice.  You can choose to work with local leaders to make things better for you and your family right now and then worry about national politics tomorrow.  That is why counter-insurgency can work.

The good news is that we have graduated from the distractions of “death panels” to the core political battles in health care reform.  The bad news is that last weeks attack line of Republicans switched from promoting cost savings to defending medical pork for private insurance companies.   The Democrats support plans that would cut back the 14 percent extra payments to Medicare Part C plans, private health care plans that must provide the same health care benefits as traditional Medicare Parts A and B.  The Republican correctly assert that Part C plans offer some extra benefits and that Part C beneficiaries would lose those extra benefits.

First of all it is not clear that the extra benefits or all the extra benefits would be lost because Part C plans would not be cut back to parity, thogh that could change.  The vastly more important point is that the Republican rhetoric blasts out that “Medicare beneficiaries will lose benefits” not that the the 22 percent enrolled in Part C might lose some extra benefits.  Big difference.

Just a week ago the major Republican attack line was that health care reform would cost too much and add another tax burden on taxpayers.  Then this last week they decided to attack one of the major sources of cost saving in the Democrat plans in favor of more rhetoric to scare seniors.

The mendacity of this maneuver, and Republicans do not have a monopoly on misrepresentation, has an interesting history.  For decades, many Republicans and some Democrats believed that managed care as a way to deliver health care services had huge potential advantages.  I agree that there might be some advantages, particularly in comparison to fee-for-service private health insurance, but no advantages have showed up in comparison to fee-for-service traditional Medicare which has been more successful in cutting costs than private insurance.
Back in 1997 the Republicans argued that privately run managed care was more efficient than traditional Medicare and asked for only 95 percent of traditional Medicare costs.  The Part C plans, which turned out, over time, to be mostly Preferred Provider Plans (PPOs), also were allowed to offer some additional services as part of the plans.  Different Part C plans offered different additional services: dental, vision, and prescription drug services, for the most part.  Part C did not work out well and there was little take up.

In 2003, as part of the Medicare prescription drug legislation, Republicans took another bite of the apple, renamed Part C as Medicare Advantage, and instead of saving money gave Part C plans bonuses that have grown currently to 14 percent.  Part C plans continue to offer some additional services such as membership in health clubs and some vision and dental care.  To put the relevant cost savings in perspective, the Part C plans reported that they spend 83.3 percent of their revenue on health care services and took profits of 6.6 percent.  Medicare reports a 1.4 percent administrative costs and, of course, no profits.

The 83.3 percent that Part C plans paid for health care services presumably covers all services provided including whatever extra benefits are provided so the claim of plans that they should get higher revenues because they provide more services doesn’t stand up.  A more fundamental equity point is that if these extra services are valuable, and they sound somewhat valuable to me, they should be available to all Medicare beneficiaries, not just the 22 percent enrolled in Part C.  If the Republicans will support offering these benefits only as marketing incentives for the private Part C plans, and that appears to be their position, then their commitment to medical pork is all the more glaring.

The Republican position is not that hard to explain.  They get a lot more money in political contributions from private insurers than the Democrats.  It is not surprising that private health insurers give their contributions mostly to the Republicans because Republicans have fought Medicare from its inception, calling it socialized medicine and an inefficient federal bureaucracy.  Traditional Medicare can be improved and there are some things in the health care reform plans of the Democrats that would make improvements.  But even without the improvements traditional Medicare is far more efficient than Medicare Part C and private health insurance in general, as measured by the percentage of dollars coming in that are spent on health care services.

If current benificiaries in Part C want to keep their extra benefits they should argue for the benefits for everyone receiving Medicare.  If Medicare Part C can’t compete on a level playing field then it should dwindle back to its previous small size.  A recent New York Times editorial reports a comment from the Congressional Budget Office that they expect enrollement in Part C plans to remain about the same.  The main point is that the $100 billion to be saved over ten years is important for improvements in the Medicare program, to the people in the country who need coverage, to the people who have health care insurance with all the problems that health care reform will fix, and to taxpayers.