A Wake Up Call

by Robert Kuuttner, Salon.com

How could the health care issue have turned from a reform that was going to make Barack Obama ten feet tall into a poison pill for Democratic senators? Whether or not Martha Coakley squeaks through in Massachusetts on Tuesday, the health bill has already done incalculable political damage and will likely do more. Polls show that the public now opposes it by margins averaging ten to fifteen points, and widening. It is hard to know which will be the worse political defeat -- losing the bill and looking weak, or passing it and leaving it as a piñata for Republicans to attack between now and November.

The measure is so unpopular that Republican State Senator Scott Brown has built his entire surge against Coakley around his promise to be the 41st senator to block the bill -- this in Ted Kennedy's Massachusetts. He must be pretty confident that the bill has become politically radioactive, and he's right.

It has already brought down Senator Byron Dorgan of North Dakota, a fighter for health care and other reforms far more progressive than President Obama's. Dorgan championed Americans' right to re-import cheaper prescription drugs from Canada, a popular provision that the White House blocked. Dorgan, who is one of the Senate's great populists, began the year more than twenty points ahead in the polls of his most likely challenger, North Dakota Governor John Hoeven. By the time he decided to call it a day, Dorgan was running more than twenty points behind. The difference was the health bill, which North Dakotans oppose by nearly two to one. The fact that Dorgan's own views were much better than the Administration's cut little ice. He was fatally associated with an unpopular bill.

So, how did Democrats get saddled with this bill? Begin with Rahm Emanuel. The White House chief of staff, who was once Bill Clinton's political director, drew three lessons from the defeat of Clinton-care. All three were wrong. First, get it done early (Clinton's task force had dithered.) Second, leave the details to Congress (Clinton had presented Congress with a fully-baked cake.) Third, don't get on the wrong side of the insurance and drug industries (The insurers' fictitious couple, Harry and Louise, had cleaned Clinton's clock.)

But as I wrote in Obama's Challenge, in August 2008, it would be a huge mistake to try to get health care done right out of the box. Obama first needed to get his sea-legs, and focus like a laser on economic recovery. If he got the economy back on track, he would then have earned the chops to undertake more difficult structural reforms like health care.

Deferring to the House and Senate was fine up to a point, but this was an issue where the president needed to lead as only presidents can -- in order to frame the debate and define the stakes.

Cutting a deal with the insurers and drug companies, who are not exactly candidates to win popularity contests, associated Obama with profoundly resented interest groups. This was exactly the wrong framing. This battle should have been the president and the people versus the interests. Instead more and more voters concluded that it was the president and the interests versus the people.

As policy, the interest-group strategy made it impossible to put on the table more fundamental and popular reforms, such as using Federal bargaining power to negotiate cheaper drug prices, or having a true public option like Medicare-for-all. Instead, a bill that served the drug and insurance industries was almost guaranteed to have unpopular core elements.

The politics got horribly muddled. By embracing a deal that required the government to come up with a trillion dollars of subsidy for the insurance industry, Obama was forced to pursue policies that were justifiably unpopular -- such as taxing premiums of people with decent insurance; or compelling people to buy policies that they often couldn't afford, or diverting money from Medicare. He managed to scare silly the single most satisfied clientele of our one island of efficient single-payer health insurance -- senior citizens -- and to alienate one of his most loyal constituencies, trade unionists.

The bill helped about two-thirds of America's uninsured, but did almost nothing for the 85 percent of Americans with insurance that is becoming more costly and unreliable by the day -- except frighten them into believing that what little they have is at increased risk of being taken away.

All of this made things easier for the right, and left people to take seriously even preposterous allegations such as the nonsense about death panels. It got so ass-backwards that the other day Ben Nelson, who successfully held out for anti-abortion language and a sweetheart deal for Nebraska's Medicaid as the price of his vote, found himself facing a wholesale voter backlash.

Nelson began running TV spots assuring Nebraska voters that the Obama health plan is "not run by the government." That's one hell of a slogan for a party that relies on democratically elected government to offset the insecurity, inequality and insanity generated by private commercial forces. If not-run-by-government is the Democrats' credo, why bother?

So we went from a politics in which government is necessary to provide secure health insurance -- because the private insurance industry skims off outrageous middlemen fees and discriminates against sick people -- to a politics in which Democrats, as a matter of survival, feel they have to apologize for government. Thank you, Rahm Emanuel.

The budget-obsessives around Obama also insisted that most of the bill not take effect until 2013, so that all of the scary stuff gets three years to fester before most people see any benefit. Call it political malpractice.

Finally, the health insurance battle sucked out all the oxygen. When Obama made time to work the phones personally, it wasn't to enact serious financial reform (this was left to the tender mercies of Tim Geithner) or to fight for a real jobs program (deficit hawks Peter Orszag and Larry Summers got to blunt that one). No -- Obama got on the phone and met with legislators to round up the last vote or two for a sketchy health reform that crowded out far more urgent issues.

As a resident of Massachusetts, in the last two days I've gotten robo calls from Barack Obama, Joe Biden, Bill Clinton, Martha Coakley, and Angela Menino, the wife of Boston's mayor -- everyone but the sainted Ted Kennedy. In Obama's call, he advised me that he needed Martha Coakley in the Senate, "because I'm fighting to curb the abuses of a health insurance industry that routinely denies care." Let's see, would that be the same insurance industry that Rahm was cutting inside deals with all spring and summer? The same insurance industry that spent tens of millions on TV spots backing Obama's bill as sensible reform?

If voters are wondering which side this guy is on, he has given them good reason.

Looking forward, one can imagine several possibilities. Suppose Coakley loses. Obama and the House leadership may then decide that their one shot to salvage health reform after all this effort is for the House to just pass the Senate-approved bill and send it to the president's desk. They can fix its deficiencies later. This is an easy parliamentary move. But the bill passed the House by only five votes; many House members are dead set against some of the more objectionable provisions of the Senate bill; a Coakley loss would make the bill that much more politically toxic; there will be Republican catcalls that Congress is using dubious means to pass a bill that has just been politically repudiated; and the House votes just may not be there this time.

Alternatively, let's say Coakley narrowly wins, the Democrats have a near death experience, and the House and Senate stop squabbling and pass the damned bill.

Either way, the Massachusetts surprise should be a wake-up call of the most fundamental kind. Obama needs to stop playing inside games with bankers and insurance lobbyists, and start being a fighter for regular Americans. Otherwise, he can kiss it all goodbye.

Robert Kuttner is co-editor of The American Prospect, a senior fellow at Demos, and author of Obama's Challenge.

A Less Than Honest Policy

By BOB HERBERT, NY Times, December 29, 2009

There is a middle-class tax time bomb ticking in the Senate’s version of President Obama’s effort to reform health care.

The bill that passed the Senate with such fanfare on Christmas Eve would impose a confiscatory 40 percent excise tax on so-called Cadillac health plans, which are popularly viewed as over-the-top plans held only by the very wealthy. In fact, it’s a tax that in a few years will hammer millions of middle-class policyholders, forcing them to scale back their access to medical care.

Which is exactly what the tax is designed to do.

The tax would kick in on plans exceeding $23,000 annually for family coverage and $8,500 for individuals, starting in 2013. In the first year it would affect relatively few people in the middle class. But because of the steadily rising costs of health care in the U.S., more and more plans would reach the taxation threshold each year.

Within three years of its implementation, according to the Congressional Budget Office, the tax would apply to nearly 20 percent of all workers with employer-provided health coverage in the country, affecting some 31 million people. Within six years, according to Congress’s Joint Committee on Taxation, the tax would reach a fifth of all households earning between $50,000 and $75,000 annually. Those families can hardly be considered very wealthy.

Proponents say the tax will raise nearly $150 billion over 10 years, but there’s a catch. It’s not expected to raise this money directly. The dirty little secret behind this onerous tax is that no one expects very many people to pay it. The idea is that rather than fork over 40 percent in taxes on the amount by which policies exceed the threshold, employers (and individuals who purchase health insurance on their own) will have little choice but to ratchet down the quality of their health plans.

These lower-value plans would have higher out-of-pocket costs, thus increasing the very things that are so maddening to so many policyholders right now: higher and higher co-payments, soaring deductibles and so forth. Some of the benefits of higher-end policies can be expected in many cases to go by the boards: dental and vision care, for example, and expensive mental health coverage.

Proponents say this is a terrific way to hold down health care costs. If policyholders have to pay more out of their own pockets, they will be more careful — that is to say, more reluctant — to access health services. On the other hand, people with very serious illnesses will be saddled with much higher out-of-pocket costs. And a reluctance to seek treatment for something that might seem relatively minor at first could well have terrible (and terribly expensive) consequences in the long run.

If even the plan’s proponents do not expect policyholders to pay the tax, how will it raise $150 billion in a decade? Great question.

We all remember learning in school about the suspension of disbelief. This part of the Senate’s health benefits taxation scheme requires a monumental suspension of disbelief. According to the Joint Committee on Taxation, less than 18 percent of the revenue will come from the tax itself. The rest of the $150 billion, more than 82 percent of it, will come from the income taxes paid by workers who have been given pay raises by employers who will have voluntarily handed over the money they saved by offering their employees less valuable health insurance plans.

Can you believe it?

I asked Richard Trumka, president of the A.F.L.-C.I.O., about this. (Labor unions are outraged at the very thought of a health benefits tax.) I had to wait for him to stop laughing to get his answer. “If you believe that,” he said, “I have some oceanfront property in southwestern Pennsylvania that I will sell you at a great price.”

A survey of business executives by Mercer, a human resources consulting firm, found that only 16 percent of respondents said they would convert the savings from a reduction in health benefits into higher wages for employees. Yet proponents of the tax are holding steadfast to the belief that nearly all would do so.

“In the real world, companies cut costs and they pocket the money,” said Larry Cohen, president of the Communications Workers of America and a leader of the opposition to the tax. “Executives tell the shareholders: ‘Hey, higher profits without any revenue growth. Great!’ ”

The tax on health benefits is being sold to the public dishonestly as something that will affect only the rich, and it makes a mockery of President Obama’s repeated pledge that if you like the health coverage you have now, you can keep it.

Those who believe this is a good idea should at least have the courage to be straight about it with the American people.

Debate Shows Obama Plays by Washington’s Rules

By ADAM NAGOURNEY, NY Times, December 26, 2009

WASHINGTON — Howard Dean ran for president in 2004 as the outsider ready to battle an entrenched establishment in Washington. And so, four years later, did Barack Obama.

Now, one year into Mr. Obama’s presidency, a sharp dispute between the president and Mr. Dean over the health care bill the Senate approved Thursday — Mr. Dean denounced it as a sellout, while Mr. Obama heralded it as a historic breakthrough — is illustrating the roots of the ideological breach within the Democratic party.

It is not just that the left wing of the party thinks that its centrists hold too much sway and are too quick to cave when faced with pressure from the right. It is also that this White House, stocked as it is with insiders, people whose view of politics is shaped by the compromises inherent in legislating, is confronting a liberal base made up largely of outsiders to the lawmaking process who are asking why they should accept politics as usual.

As much as Mr. Obama presented himself as an outsider during his campaign, a lesson of this battle is that this is a president who would rather work within the system than seek to upend it. He is not the ideologue ready to stage a symbolic fight that could end in defeat; he is a former senator comfortable in dealing with the arcane rules of the Senate and prepared to accept compromise in search of a larger goal. For the most part, Democrats on Capitol Hill have stuck with him.

By contrast, Mr. Dean, the former Democratic Party chairman who has long had strained relations with this administration, said the White House was slow to fight and quick to make concessions — particularly on creating a public insurance plan — and demanded that Democrats kill the Senate version of the health care bill.

That sentiment was echoed by liberal efforts that grew up around the Dean campaign, notably Daily Kos and MoveOn.org, which argued that Mr. Obama was not tough enough in staring down foes, be they insurance companies or Senator Joseph I. Lieberman, the Democrat-turned-independent from Connecticut.

“He ran as someone who would fight against entrenched special interests on behalf of the little guy,” said Adam Green, co-founder of the Progressive Change Campaign Committee, which has emerged as one of Mr. Obama’s leading critics in recent days. “And what we learned in this debate is that he’s not willing to fight and exert pressure on entrenched special interests when it comes to big ideas.”

Of course, it is easier to be an outsider when you are on the outside, which is where Mr. Dean is these days, after making an unsuccessful effort to win a post in the Obama White House. And Mr. Dean’s longtime feud with Rahm Emanuel, the White House chief of staff, was noted by many Democrats who were taken aback by the sharp tenor of Mr. Dean’s attack on others in the party. (Mr. Dean declined to comment.)

Still, Mr. Obama’s approach to this battle should not be a surprise to anyone who has followed his career or his campaign for the White House. He served in the United States Senate and in the Illinois Senate. His choice for chief of staff — Mr. Emanuel — was the No. 3 person in the House Democratic leadership, and many of his top West Wing aides came out of staff jobs in the Senate.

Mr. Obama may find it frustrating that it is impossible under Senate rules to get something through without 60 votes, but those are the rules and he is going to play by them. He was not about to go to Connecticut and to whip up the public against Mr. Lieberman, or to press for him to be relieved of his leadership positions in the Senate, as Mr. Green suggested he do.

“The president wasn’t after a Pyrrhic victory — he wasn’t into symbolism,” said David Axelrod, a senior adviser to Mr. Obama. “The president is after solving a problem that has bedeviled a country and countless families for generations.”

All of this has come at a time of strains between Mr. Obama and the left. Mr. Obama has come under fire on several fronts, like health care, escalation of the war in Afghanistan and his failure so far to make good on a campaign pledge to end the ban on open homosexuals in the military.

Mr. Obama has moved to the center on some issues since he became president, particularly on elements of national security. Still, he never presented himself as a doctrinaire liberal, and much of what he is doing as president tracks with what he talked about during the campaign.

Mr. Obama’s call to send more troops to Afghanistan is what he always talked about in the context of outlining his opposition to the war in Iraq. “It’s not like he woke up one morning and said, ‘Let’s go fight a war in Afghanistan,’ ” Mr. Emanuel said. “He talked about it in the campaign.”

And Mr. Obama never exhibited the left’s passion for establishing a public insurance option as part of an overhaul of health care. He rarely talked about it during scores of debates, speeches and interviews during the campaign; instead he focused on expanding coverage, lowering costs and ending health insurance abuses.

During the campaign, many people saw in Mr. Obama what they wanted to see in him, and in the Democratic primaries he often appealed more directly to the left than did Hillary Rodham Clinton, his main rival for most of the contest. The question now is whether legislative and policy accomplishment — signing a health care bill, however imperfect in the eyes of liberals, steadying the economy, winding down the war in Iraq — will be enough, assuming Mr. Obama achieves them, to maintain the support and enthusiasm of those on the left who wanted even more from him.

Mr. Green said that Mr. Obama’s failure to push for the public option — or to enlist his network of grass-root supporters behind it — had sapped the energy out of the base and would have consequences for the 2010 elections. If Mr. Green is correct, that could be a real problem for Democrats, particularly given how energetic opposition to the health bill and the entire Obama agenda appears to be among Republicans.

But this could also prove to be a test of just how much power the outside voices in the left wing have over the insiders in the White House and on Capitol Hill. The stinging attack from Mr. Dean and organizations on the left calling for the defeat of the health care bill failed to dissuade a single Senate Democrat from voting for it. And Mr. Axelrod said he was not worried that would hurt the party come November.

“When people focus on what this bill is and not what it isn’t and recognize what an enormous landmark achievement it is, progressive achievement, you’ll see folks rallying around this and not running away from it,” he said.

White House as helpless victim on healthcare

Nonsense. The administration is getting the bill that it -- more or less -- wanted all along The evidence was overwhelming from the start that the White House was not only indifferent, but opposed, to the provisions most important to progressives. The administration is getting the bill which they, more or less, wanted from the start -- the one that is a huge boon to the health insurance and pharmaceutical industry. And kudos to Russ Feingold for saying so:

Glenn Greenwald

Dec. 16, 2009

(Updated below - Update II - Update III - Update IV - Update V)

Of all the posts I wrote this year, the one that produced the most vociferious email backlash -- easily -- was this one from August, which examined substantial evidence showing that, contrary to Obama's occasional public statements in support of a public option, the White House clearly intended from the start that the final health care reform bill would contain no such provision and was actively and privately participating in efforts to shape a final bill without it. From the start, assuaging the health insurance and pharmaceutical industries was a central preoccupation of the White House -- hence the deal negotiated in strict secrecy with Pharma to ban bulk price negotiations and drug reimportation, a blatant violation of both Obama's campaign positions on those issues and his promise to conduct all negotiations out in the open (on C-SPAN). Indeed, Democrats led the way yesterday in killing drug re-importation, which they endlessly claimed to support back when they couldn't pass it. The administration wants not only to prevent industry money from funding an anti-health-care-reform campaign, but also wants to ensure that the Democratic Party -- rather than the GOP -- will continue to be the prime recipient of industry largesse.

As was painfully predictable all along, the final bill will not have any form of public option, nor will it include the wildly popular expansion of Medicare coverage. Obama supporters are eager to depict the White House as nothing more than a helpless victim in all of this -- the President so deeply wanted a more progressive bill but was sadly thwarted in his noble efforts by those inhumane, corrupt Congressional "centrists." Right. The evidence was overwhelming from the start that the White House was not only indifferent, but opposed, to the provisions most important to progressives. The administration is getting the bill which they, more or less, wanted from the start -- the one that is a huge boon to the health insurance and pharmaceutical industry. And kudos to Russ Feingold for saying so:

Sen. Russ Feingold (D-Wis.), among the most vocal supporters of the public option, said it would be unfair to blame Lieberman for its apparent demise. Feingold said that responsibility ultimately rests with President Barack Obama and he could have insisted on a higher standard for the legislation.

"This bill appears to be legislation that the president wanted in the first place, so I don’t think focusing it on Lieberman really hits the truth," said Feingold. "I think they could have been higher. I certainly think a stronger bill would have been better in every respect."

Let's repeat that: "This bill appears to be legislation that the president wanted in the first place." Indeed it does. There are rational, practical reasons why that might be so. If you're interested in preserving and expanding political power, then, all other things being equal, it's better to have the pharmaceutical and health insurance industry on your side than opposed to you. Or perhaps they calculated from the start that this was the best bill they could get. The wisdom of that rationale can be debated, but depicting Obama as the impotent progressive victim here of recalcitrant, corrupt centrists is really too much to bear.

Yet numerous Obama defenders -- such as Matt Yglesias, Ezra Klein and Steve Benen -- have been insisting that there is just nothing the White House could have done and all of this shows that our political system is tragically "ungovernable." After all, Congress is a separate branch of government, Obama doesn't have a vote, and 60 votes are needed to do anything. How is it his fault if centrist Senators won't support what he wants to do? Apparently, this is the type of conversation we're to believe takes place in the Oval Office:

The President: I really want a public option and Medicare buy-in. What can we do to get it?

Rahm Emanuel: Unfortunately, nothing. We can just sit by and hope, but you're not in Congress any more and you don't have a vote. They're a separate branch of government and we have to respect that.

The President: So we have no role to play in what the Democratic Congress does?

Emanuel: No. Members of Congress make up their own minds and there's just nothing we can do to influence or pressure them.

The President: Gosh, that's too bad. Let's just keep our fingers crossed and see what happens then.

In an ideal world, Congress would be -- and should be -- an autonomous branch of government, exercising judgment independent of the White House's influence, but that's not the world we live in. Does anyone actually believe that Rahm Emanuel (who built his career on industry support for the Party and jamming "centrist" bills through Congress with the support of Blue Dogs) and Barack Obama (who attached himself to Joe Lieberman when arriving in the Senate, repeatedly proved himself receptive to "centrist" compromises, had a campaign funded by corporate interests, and is now the leader of a vast funding and political infrastructure) were the helpless victims of those same forces? Engineering these sorts of "centrist," industry-serving compromises has been the modus operandi of both Obama and, especially, Emanuel.

Indeed, we've seen before what the White House can do -- and does do -- when they actually care about pressuring members of Congress to support something they genuinely want passed. When FDL and other liberal blogs led an effort to defeat Obama's war funding bill back in June, the White House became desperate for votes, and here is what they apparently did (though they deny it):

The White House is playing hardball with Democrats who intend to vote against the supplemental war spending bill, threatening freshmen who oppose it that they won't get help with reelection and will be cut off from the White House, Rep. Lynn Woolsey (D-Calif.) said Friday. "We're not going to help you. You'll never hear from us again," Woolsey said the White House is telling freshmen.

That's what the White House can do when they actually care about pressuring someone to vote the way they want. Why didn't they do any of that to the "centrists" who were supposedly obstructing what they wanted on health care? Why didn't they tell Blanche Lincoln -- in a desperate fight for her political life -- that she would "never hear from them again," and would lose DNC and other Democratic institutional support, if she filibustered the public option? Why haven't they threatened to remove Joe Lieberman's cherished Homeland Security Chairmanship if he's been sabotaging the President's agenda? Why hasn't the President been rhetorically pressuring Senators to support the public option and Medicare buy-in, or taking any of the other steps outlined here by Adam Green? There's no guarantee that it would have worked -- Obama is not omnipotent and he can't always control Congressional outcomes -- but the lack of any such efforts is extremely telling about what the White House really wanted here.

Independent of the reasonable debate over whether this bill is a marginal improvement over the status quo, there are truly horrible elements to it. Two of the most popular provisions (both of which, not coincidentally, were highly adverse to industry interests) -- the public option and Medicare expansion -- are stripped out (a new Washington Post/ABC poll out today shows that the public favors expansion of Medicare to age 55 by a 30-point margin). What remains is a politically distastrous and highly coercive "mandate" gift to the health insurance industry, described perfectly by Digby:

Obama can say that you're getting a lot, but also saying that it "covers everyone," as if there's a big new benefit is a big stretch. Nothing will have changed on that count except changing the law to force people to buy private insurance if they don't get it from their employer. I guess you can call that progressive, but that doesn't make it so. In fact, mandating that all people pay money to a private interest isn't even conservative, free market or otherwise. It's some kind of weird corporatism that's very hard to square with the common good philosophy that Democrats supposedly espouse.

Nobody's "getting covered" here. After all, people are already "free" to buy private insurance and one must assume they have reasons for not doing it already. Whether those reasons are good or bad won't make a difference when they are suddenly forced to write big checks to Aetna or Blue Cross that they previously had decided they couldn't or didn't want to write. Indeed, it actually looks like the worst caricature of liberals: taking people's money against their will, saying it's for their own good --- and doing it without even the cover that FDR wisely insisted upon with social security, by having it withdrawn from paychecks. People don't miss the money as much when they never see it.

In essence, this reinforces all of the worst dynamics of Washington. The insurance industry gets the biggest bonanza imaginable in the form of tens of millions of coerced new customers without any competition or other price controls. Progressive opinion-makers, as always, signaled that they can and should be ignored (don't worry about us -- we're announcing in advance that we'll support whatever you feed us no matter how little it contains of what we want and will never exercise raw political power to get what we want; make sure those other people are happy but ignore us). Most of this was negotiated and effectuated in complete secrecy, in the sleazy sewers populated by lobbyists, industry insiders, and their wholly-owned pawns in the Congress. And highly unpopular, industry-serving legislation is passed off as "centrist," the noblest Beltway value.

Looked at from the narrow lens of health care policy, there is a reasonable debate to be had among reform advocates over whether this bill is a net benefit or a net harm. But the idea that the White House did what it could to ensure the inclusion of progressive provisions -- or that they were powerless to do anything about it -- is absurd on its face. Whatever else is true, the overwhelming evidence points to exactly what Sen. Feingold said yesterday: "This bill appears to be legislation that the president wanted in the first place."

UPDATE: It's also worth noting how completely antithetical claims are advanced to defend and excuse Obama. We've long heard -- from the most blindly loyal cheerleaders and from Emanuel himself -- that progressives should place their trust in the Obama White House to get this done the right way, that he's playing 11-dimensional chess when everyone else is playing checkers, that Obama is the Long Game Master who will always win. Then, when a bad bill is produced, the exact opposite claim is hauled out: it's not his fault because he's totally powerless, has nothing to do with this, and couldn't possibly have altered the outcome. From his defenders, he's instantaneously transformed from 11-dimensional chess Master to impotent, victimized bystander.

The supreme goal is to shield him from all blame. What gets said to accomplish that goal can -- and does -- radically change from day to day.

UPDATE II: I'll be on MSNBC this afternoon at 3:00 p.m. EST with David Schuster/Tamron Hall discussing this post.

UPDATE III: Over at Politico, Jane Hamsher documents how Joe Lieberman's conduct on the health care bill provides the perfect vehicle to advance the agenda of the White House and Harry Reid. Consistent with that, she independently notes media reports that White House officials are privately expressing extreme irritation with Howard Dean for opposing the Senate bill as insufficient, but have nothing bad to say about Lieberman, who supposedly single-handedly sabotaged what the White House was hoping for in this bill.

UPDATE IV: Immediately prior to the MSNBC segment I just did -- video for which I will post when it's available -- an NBC reporter explained how Robert Gibbs used his Press Briefing today to harshly criticize Howard Dean for opposing the health care bill. Why did Gibbs never publicly criticize people like Blanche Lincoln, Ben Nelson, Joe Lieberman and the like if they were supposedly obstructing and impeding the White House's agenda on health care reform (this is a point Yglesias acknowledges as a "fair" one)? Having a Democratic White House publicly criticize a Democratic Senator can be a much more effective pressure tactic than doing so against a former Governor who no longer holds office.

Meanwhile, as one would expect, health insurance stocks are soaring today in response to the industry-serving "health care reform" bill backed by the Democratic Senate and White House -- the same people who began advocating the need for "health care reform" in order to restrain on an out-of-control and profit-inflated health insurance industry (h/t Markos).

UPDATE V: Here's the roughly 4-minute segment I did with David Shuster today

Senate rejects importation of prescription drugs

Sad, but true.. and how much are you paying for medication today? (If you're unfortunate enough to have to buy it, of course.)

The proposal had threatened to derail the Democrats' landmark healthcare bill. Meanwhile, Obama and many liberals back the decision to drop the 'public option.'

By Noam N. Levey and Janet Hook

5:01 PM PST, December 15, 2009

Reporting from Washington

In a victory for President Obama and his allies in the pharmaceutical industry, the Senate today turned aside a bid by a bipartisan group of lawmakers to make it easier to import cheaper prescription drugs from Canada and Western Europe -- a proposal that threatened to derail the Democrats' landmark healthcare bill.

The vote on the amendment -- cosponsored by Sens. Byron Dorgan (D-N.D.) and John McCain (R-Ariz.) -- was 51-48, nine short of the 60 needed to pass.

The politically charged amendment held up the Senate for a week as drug companies, the White House and lawmakers from states that are home to drug makers fought to derail the proposal. Critics, including the Food and Drug Administration, said it would be difficult to implement and hard to guarantee that imported drugs would be safe.

Further adding to the momentum for final Senate approval of the massive healthcare bill, Obama and many liberal Democrats rallied behind the decision to put aside a goal liberals had long held as an article of faith -- a new government health insurance plan to compete with the private sector.

Obama summoned Senate Democrats to the White House today to urge them not to let disagreements over details of the legislation derail or delay the landmark effort.

"This reform has to pass on our watch," the president said. "We are on the precipice of an achievement that has eluded Congresses and presidents for decades."

While some liberals mourned the capitulation that has long seemed inevitable, leaders of several progressive groups signaled that they would support the strategy for now rather than risk stalling their drive.

"The final bill won't include everything that everybody wants," Obama said.

The president weighed in at a critical moment, as Senate Majority Leader Harry Reid (D-Nev.) was working to unite their party in advance of key votes on the compromise that did not include the so-called "public option" -- a new government-run health insurance plan -- or an alternative plan to expand Medicare, which was popular with liberals.

A vast array of details have yet to be pinned down, but the framework of the Senate bill came into view as Reid pushed the Senate to finish work before Christmas. The sense of gathering momentum was fueled as disputes on other issues were resolved: Behind-the-scenes negotiations continued to resolve differences among Democrats over restrictions on federal funding for abortion.

The drug amendment had in the past enjoyed broad support from Democrats -- including Obama -- but the White House and Senate leaders bowed to the pharmaceutical industry and joined their effort to derail it. The administration feared that if the amendment had passed, pharmaceutical companies, which earlier this year struck a deal with the White House to limit the economic impact of a healthcare overhaul on their industry, would turn against the broader health legislation.

To appease critics, Reid pledged this week to work with House leaders to ensure that a final bill would close the so-called Medicare doughnut hole, a gap in prescription drug coverage that forces millions of seniors to pay for thousands of dollars of drugs out of their own pockets.

On the broader questions, Reid plans to unveil the details of his final compromise Wednesday after receiving an official report on its costs and impact. After that, Reid is expected to begin the complex procedural steps required to cut off Republicans' filibuster, with the first of a series of crucial votes coming as early as Friday.

Without any GOP support, all 60 lawmakers in the Democratic caucus, including two independents, will have to vote for the procedural motions in order for the bill to advance. It will then have to be reconciled with a version passed last month by the House, a stronger bulwark of liberalism than the Senate.

House Democrats welcomed the apparent end of the Senate's stalemate on the legislation, but were not happy about the drift of its compromises.

"We in the House have made a beautiful souffle, but the Senate has scrambled an egg," said Rep. George Miller (D-Martinez), noting that Reid already had said he expected to go along with the House in closing the Medicare doughnut hole. "Let's hope they will find more they like in the House bill."

Some liberals pledged to vote against the bill if it is in the Senate mold, but Democratic leaders steered clear of such ultimatums. House Majority Leader Steny Hoyer (D-Md.) told reporters that the House could pass the health bill without a public option, contrary to earlier warnings. That was in keeping with advice Democrats say they received long ago from Obama lieutenants like Chief of Staff Rahm Emanuel, who argued that passing any bill would be better than failing to act.

"Rahm told us months ago: Everything can be compromised except our ultimate goal of getting something done," said Rep. Jim Moran (D-Va.). "Everything else is negotiable."

And liberals acknowledged they were in a weak bargaining position because conservatives were willing to kill the bill over their disagreements -- and Democrats were not.

"We progressives are negotiating with a gun to our heads," said Rep. Anthony Weiner (D-N.Y.). "Our opponents are saying, 'Go ahead and shoot.' If you're a public option fan, you haven't had a good week."

The final push for Senate action picked up important support today from several leading consumer groups, including AARP, the American Cancer Society Cancer Action Network, Consumers Union and Families USA. The groups plan to join the Service Employees International Union, which has been a leading advocate for a new government insurance plan, at the Capitol on Wednesday to urge senators to quash a Republican-led filibuster next week.

And Health Care for America Now, the influential coalition of liberal activist groups, today decided to send a letter to Reid calling for passage of the legislation, the group's campaign manager Richard Kirsch said.

"There are major problems with the Senate bill," Kirsch said in an interview today. "But if the Senate doesn't act, there will be no healthcare reform. . . . The place to fix [the Senate bill] is in a conference committee" with House and Senate leaders at the table.

The White House meeting came one day after Senate Democrats moved to back down from the idea of expanding Medicare in lieu of the public option, bowing to opposition from conservative Democrats and independent Sen. Joe Lieberman of Connecticut. Democrats were infuriated at Lieberman because he had supported the expansion of Medicare in the past, but the White House tried to defuse that anger.

"If we held flip-flops against everybody in the Congress, we'd probably not have many people there," Vice President Joe Biden said in an interview on MSNBC's "Morning Joe" program.

Lieberman joined Obama and Democrats at the White House and signaled that he planned to vote for the bill, according to sources briefed on the meeting. Obama urged others to see the glass as half full, emphasizing that the legislation, like the landmark 1965 law that created Medicare, is a foundation for further improvements in the future.

"Be joyful; be grateful," Obama said, according to Senate Finance Committee Max Baucus (D-Mont.). "We'll build upon it in the future."

In his public comments after the meeting, he said that the emerging Senate bill meets the major criteria he set out in a healthcare speech before a joint session of Congress: It would expand coverage, does not add to the deficit, and slows the rate of growth of healthcare costs.

Beyond that, Obama said, "We simply cannot allow differences over individual elements of this plan to prevent us from meeting our responsibility to solve a long-standing and urgent problem for the American people," Obama said. "They are waiting for us to act. They are counting on us to show leadership. And I don't intend to let them down."

Neither does as staunch a liberal as Sen. Sherrod Brown (D-Ohio), who has steadfastly refused to compromise on including a public option. He said after meeting with Obama that he would vote for the bill despite his reservations.

"There is too much at stake," he said. "And it's about me. It's not about any senator. It's not about Lieberman."

noam.levey@latimes.com

janet.hook@latimes.com

Senate healthcare bill: Time to kill it?

Is reform without public option worth it? Markos, Ezra Klein, Paul Krugman, Howard Dean and others weigh in

Some progressives say that without a public option, it is. Others on the left say any progress is better than none

Thomas Schaller

Dec. 15, 2009

Is the watered-down, no-public-option healthcare reform bill worth saving? Or should it be killed? That is the question on everyone's lips today.

By Twitter, Markos of Daily Kos let it be known where he and many progressives stand on the issue: "Insurance companies win. Time to kill this monstrosity coming out of the Senate."

That specific tweet, and the broad sentiment that underlies it, is generating quite a bit of response. The WaPo's Ezra Klein writes on his blog:

The core of this legislation is as it always was: $900 billion, give or take, so people who can't afford health-care insurance suddenly can. Insurance regulations paired with the individual mandate, so insurers can't discriminate against the sick and the healthy can't make insurance unaffordable by hanging back until the moment they need medical care. The construction of health insurance exchanges so the people currently left out of the employer-based market are better served, and the many who will join them as the employer system continues to erode will have somewhere to go.

That's all policy. And as I spent yesterday arguing, it has a tendency to overshadow the lives in the balance. You can choose your estimate. The Institute of Medicine's methodology says 22,000 people died in 2006 because they didn't have health-care coverage. A recent Harvard study found the number nearer to 45,000. Since we talk about the costs of health-care reform over a 10-year period, may as well talk about the lives saved that way, too. And we're looking, easily, at more than a hundred thousand lives, to say nothing of the people who will be spared bankruptcy, chronic pain, unnecessary impairment, unnecessary caretaking, bereavement, loss of wages, painful surgeries, and so on.

A lot of progressives woke up this morning feeling like they lost. They didn't. The public option and its compromised iterations were a battle that came to seem like a war. But they weren't the war. The bill itself was. When liberals talked about the dream of universal health-care insurance 10, 20 and 30 years ago, they talked about the plight of the uninsured, not the necessity of a limited public option in competition with private insurers.

Salon reached out to others with strong opinions on this issue, and we will be updating this post as reactions come in, so stay tuned.

In contrast to Klein, Stephanie Taylor, co-founder of Progressive Change Campaign Committee, told us:

The "Joe Lieberman Senate Bill" is ugly. Democrats stand on the verge of ushering in a world of nearly unregulated mandates, in which we're all forced by the state to hand over our money to failed private monopolies, with no cost control in return. Without a public option and no hope of expanding Medicare coverage, this bill is not worth supporting.

We got to this point due to a complete failure of leadership by President Obama--who chose to negotiate with out-of-touch senators instead of rallying their own constituents against them. It's also a failure of leadership by Harry Reid, who failed to exert any leverage over Joe Lieberman--by threatening to take away his committee chairmanship or use reconciliation to make his vote irrelevant.

When Democratic leaders refuse to fight, they can't then ask progressives to cave with them. The Progressive Change Campaign Committee is continuing to fight for the best health care bill possible, and we're intent on holding Democrats' feet to the fire. But we need to think very seriously about whether there will be a moment when it is clear that the bill does more harm than good--we need to be prepared to kill the bill.

Part of being a great negotiator is being able to walk away.

Jonathan Cohn, author of Sick and writer for the New Republic, more closely echoed Klein's view:

Is health care reform without a public option still worth passing? Unequivocally, unambiguously yes.

The case for is simple and straightforward: 30 million additional people, maybe more, will have health insurance. Many more who have insurance will see their coverage become more stable. The ability of insurers to exclude people based on pre-existing conditions will diminish significantly, if not disappear. And that's on top of a host of delivery reforms which should, in combination, help make medical care less expensive over time. The bill could be much better, for sure, but to argue that it's worse than nothing you have to make the case that nothing will somehow lead to more progress in some reasonable frame of time.

I don't see that. Failure to pass health reform won't lead to a progressive revival or resurgence. It will cripple the Democrats, hand the Republicans more political power, and likely to send health care reform into hibernation for another ten to twenty years. It's theoretically possible we could get a better reform at that point. But the historical trend is in the opposite direction. Every new effort is a less ambition version of the old one. Meantime, millions of more people would suffer.

Pass this bill now. Improve it later. That's the way we do things in America, for better or for worse.

The Lost Weekend

By GAIL COLLINS

The Senate is going to be in session all weekend, debating the big health care bill and arguing about which direction the cost-curve is heading. This is a positive development on two counts. It keeps senators off the streets while providing much-needed employment in the chart-making sector of our economy.

Or we could just lock them in a basement until they’re done squabbling. Either way is good, but the basement option would have the advantage of covering some of the less-active debaters with an attractive coat of mildew. In any case, I guarantee you that the number of normal Americans who will pay attention can be numbered in the low single digits.

So as a public service to the nonlistening audience, let me give you a summary of the important action so far:

ROUND ONE Republicans: Let’s get rid of all the Medicare savings in the bill. Think of the seniors!

Democrats: Yettaruttayetta.

ROUND TWO Mammograms! Everybody loves them. Can’t have enough.

ROUND THREE Republicans: Let’s get rid of part of the Medicare savings in the bill. Think of the seniors!

Democrats: Ruttayettarutta.

Is that perfectly clear? Good. Now we will return to our regularly scheduled conversation. Did you see that hot reality show “Hoarders” on A&E the other night? What about that lady who hoarded her dead cats? If “Hoarders” gets superpopular, do you think lots of people will start putting dead cats in their living room just so they can get on TV and be famous? Maybe somebody will try to bring dead cats to a state dinner at the White House! Does the Secret Service have a plan to avert this?

Sorry. I’ll behave. Back to the health care bill.

The Republicans are the fiscal conservatives in Congress, at least in the years when they aren’t actually in power. They were never going to rally around an expensive new government program that fails to provide a single new market for corn-based products.

But you would expect them to try to push the whole project in the most economical direction possible.

For instance, the bill would establish an independent commission on Medicare payment rates. This is a very big deal and you are going to have to take my word that health care economists fall over with excitement when it comes up.

But the Senate Democrats’ current version of the bill would only allow the panel experts to act when Medicare spending rises at a faster rate than other health care spending. Since health care spending has been going through the roof, we’re talking about waiting until Medicare spending goes through the ozone layer.

Obviously, this is an area where the Republicans would want to swing into action. And they did. They prepared an amendment eliminating the Medicare panel entirely.

In fact, G.O.P. senators appear to have amendments aimed at wiping out virtually all the cost-cutting the Democrats have put in the bill, including productivity adjustments and incentives for innovation in health care delivery.

If they can’t kill the bill completely, Republicans who are not from Maine seem intent on raising its price tag. While terrifying senior citizens in a cynical attempt to influence their vote in the next election cycle. Although I’m sure Senator Tom Coburn of Oklahoma just misspoke when he said: “I have a message for you: You’re going to die sooner."

On Friday, much of the debate was directed at Medicare Advantage. This is a program that flourished during the privatization craze. And like many attempts to save money by shoehorning private businesses into government programs, it wound up costing a ton. The Medicare Advantage policyholders cost the government 14 percent more than regular Medicare recipients, although they do often get extra benefits, sometimes including free Band-Aids or gym memberships.

Now let us be fair. There are some good services in the Advantage mix, and gym memberships are in and of themselves a fine thing. But you would think the political party that eviscerated the Clinton stimulus plan over an appropriation for late-night basketball programs would really be ticked at the idea that we’re providing a 14 percent subsidy to some Medicare recipients so they can have access to Stairmasters.

Au contraire. In fact, on Thursday Senator Orrin Hatch proposed an amendment that would eliminate the entire $120 billion in Medicare Advantage savings from the bill.

There is no sane explanation for all this other than crass political calculation. On Thursday, Senator Michael Bennet, a Colorado Democrat who’s up for election next year, introduced an amendment specifically promising that Medicare recipients would not lose any of their current guaranteed benefits. It passed 100 to 0. Meanwhile, Colorado voters were getting robocalls from John McCain warning that the health care bill was going to cut their “vital Medicare coverage.”

Now, about those dead cats.

Goldman To Private Insurers: No Health Care Reform At All Is Best

A Goldman Sachs analysis of health care legislation has concluded that, as far as the bottom line for insurance companies is concerned, the best thing to do is nothing. A close second would be passing a watered-down version of the Senate Finance Committee's bill.

A study put together by Goldman in mid-October looks at the estimated stock performance of the private insurance industry under four variations of reform legislation. The study focused on the five biggest insurers whose shares are traded on Wall Street: Aetna, UnitedHealth, WellPoint, CIGNA and Humana.

The Senate Finance Committee bill, which Goldman's analysts conclude is the version most likely to survive the legislative process, is described as the "base" scenario. Under that legislation (which did not include a public plan) the earnings per share for the top five insurers would grow an estimated five percent from 2010 through 2019. And yet, the "variance with current valuation" -- essentially, what the value of the stock is on the market -- is projected to drop four percent.

Things are much worse, Goldman estimates, for legislation that resembles what was considered and (to a certain extent) passed by the House of Representatives. This is, the firm deems, the "bear case" scenario -- in which earnings per share for the top five insurers would decline an estimated one percent from 2010 through 2019 and the variance with current valuation is projected to be negative 36 percent.

What the firm sees as the best path forward for the private insurance industry's bottom line is, to be blunt, inaction.

The study's authors advise that if no reform is passed, earnings per share would grow an estimated ten percent from 2010 through 2019, and the value of the stock would rise an estimated 59 percent during that time period.

The next best thing for the insurance industry would be if the legislation passed by the Senate Finance Committee is watered down significantly. Described as a "bull case" scenario -- in which there is "moderation of provisions in the current SFC plan" or "changes prior to the major implementation in 2013" -- earnings per share for the five biggest insurers would grow an estimated ten percent and the variance with current valuation would rise an estimated 47 percent.

The report, a Goldman official stressed, was analytic not advocacy-based. Their job was to provide a sober assessment of the market realities facing private insurers under various versions of health care reform

"If no reform at all happens you would see the largest rise in EPS," a Goldman official acknowledged. "But what we are doing is just analyzing what the stocks would do under different scenarios."

The study does note on the front page that the firm "does and seeks to do business with companies covered in its research reports." Those companies include Aetna, Wells Point and United Health.

In the context of the current health care debate, the findings provide a small window into the concerns that have driven the private insurance industry's opposition to reform legislation. Simply put: health care reform

Goldman To Private Insurers: No Health Care Reform At All Is Best

A Goldman Sachs analysis of health care legislation has concluded that, as far as the bottom line for insurance companies is concerned, the best thing to do is nothing. A close second would be passing a watered-down version of the Senate Finance Committee's bill.

A study put together by Goldman in mid-October looks at the estimated stock performance of the private insurance industry under four variations of reform legislation. The study focused on the five biggest insurers whose shares are traded on Wall Street: Aetna, UnitedHealth, WellPoint, CIGNA and Humana.

The Senate Finance Committee bill, which Goldman's analysts conclude is the version most likely to survive the legislative process, is described as the "base" scenario. Under that legislation (which did not include a public plan) the earnings per share for the top five insurers would grow an estimated five percent from 2010 through 2019. And yet, the "variance with current valuation" -- essentially, what the value of the stock is on the market -- is projected to drop four percent.

Things are much worse, Goldman estimates, for legislation that resembles what was considered and (to a certain extent) passed by the House of Representatives. This is, the firm deems, the "bear case" scenario -- in which earnings per share for the top five insurers would decline an estimated one percent from 2010 through 2019 and the variance with current valuation is projected to be negative 36 percent.

What the firm sees as the best path forward for the private insurance industry's bottom line is, to be blunt, inaction.

The study's authors advise that if no reform is passed, earnings per share would grow an estimated ten percent from 2010 through 2019, and the value of the stock would rise an estimated 59 percent during that time period.

The next best thing for the insurance industry would be if the legislation passed by the Senate Finance Committee is watered down significantly. Described as a "bull case" scenario -- in which there is "moderation of provisions in the current SFC plan" or "changes prior to the major implementation in 2013" -- earnings per share for the five biggest insurers would grow an estimated ten percent and the variance with current valuation would rise an estimated 47 percent.

The report, a Goldman official stressed, was analytic not advocacy-based. Their job was to provide a sober assessment of the market realities facing private insurers under various versions of health care reform.

"If no reform at all happens you would see the largest rise in EPS," a Goldman official acknowledged. "But what we are doing is just analyzing what the stocks would do under different scenarios."

The study does note on the front page that the firm "does and seeks to do business with companies covered in its research reports." Those companies include Aetna, Wells Point and United Health.

In the context of the current health care debate, the findings provide a small window into the concerns that have driven the private insurance industry's opposition to reform legislation. Simply put: health care reform is going to hurt their bottom line. No less a prestigious voice than Goldman Sachs is telling them so.

Some insurers, in the end, will be hit harder than others. CIGNA is the lowest of the big five, for instance, because it does little business providing insurance plans to Medicare patients, individuals and families buying health plans directly, or small employers that offer health plans to their workers.

In addition, some reforms are going to hurt the industry more than others. Regulatory changes -- such as prohibiting the prejudice against consumers with pre-existing conditions -- will have an impact across the board, as will the funding cuts to Medicare Advantage.

Overall, Goldman calculates the probability of reform passing Congress at 75 percent. Though the limitations of Goldman's political prognostications were on full display earlier in the document:

By mid-late October, we expect a cloture vote (60 votes) to bypass a potential filibuster followed by several weeks of debate over proposed amendments on the Senate floor (with a similar process under way in the House). If both the Senate and House are able to pass legislation (perhaps before the Thanksgiving recess), a House-Senate conference negotiation should produce combined legislation for final approval (perhaps by mid-December).

Jon Stewart on the Health Care (Debate? Not sure what you call it)

Health Care: Bigger, Longer and Uncut

The Daily Show With Jon Stewart	Mon - Thurs 11p / 10c
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Lieberman: I'll support Republicans in 2010

Note From Greetings: So he convinced the Dems he was with them so he could keep his chair... until he could help defeat them the next time around ... so he could keep his chair. Why would either party trust Droopy Dawg.

The senator from Connecticut almost lost his committee chair last time he stumped for the GOP

By Alex Koppelman

If you thought Sen. Joe Lieberman, I-Conn., couldn't tick off any more liberals than he did earlier this week, well, you thought wrong. It was enough for Lieberman, who managed to keep a committee chairmanship this year despite having campaigned for John McCain last year, to say he would join a Republican filibuster of a healthcare reform bill containing a public option. Now he says he could be campaigning for more candidates from the GOP next year.

"I probably will support some Republican candidates for Congress or Senate in the election in 2010. I'm going to call them as I see them," Lieberman told ABC News. "There's a hard core of partisan, passionate, hardcore Republicans,. There's a hard core of partisan Democrats on the other side. And in between is the larger group, which is people who really want to see the right thing done, or want something good done for this country and them -- and that means, sometimes, the better choice is somebody who's not a Democrat."wg? And why does he still have a chaimanship?

"America's Priorities," by the Beltway elite

Endless war in Afghanistan is an absolute necessity. Health care for Americans is a luxury that can wait.

Glenn Greenwald, Salon.com

Oct. 24, 2009

Something very unusual happened on The Washington Post Editorial Page today: they deigned to address a response from one of their readers, who "challenged [them] to explain what he sees as a contradiction in [their] editorial positions": namely, the Post demands that Obama's health care plan not be paid for with borrowed money, yet the very same Post Editors vocally support escalation in Afghanistan without specifying how it should be paid for. "Why is it okay to finance wars with debt, asks our reader, but not to pay for health care that way?"

The Post editors give two answers. They first claim that Obama will save substantial money by reducing defense spending -- by which they mean that he is merely decreasing the rate at which defense spending increases ("from 2008 to 2019, defense spending would increase only 17 percent") -- as well as withdrawing from Iraq. But so what? Even if those things really happen, we're still paying for our glorious, endless war in Afghanistan by borrowing the money from China and Japan, all of which continues to explode our crippling national debt. We have absolutely no ability to pay for our Afghan adventure other than by expanding our ignominious status as the largest and most insatiable debtor nation which history has ever known. That debt gravely bothers Beltway elites like the Post editors when it comes to providing ordinary Americans with basic services (which Post editors already enjoy), but it's totally irrelevant to them when it comes to re-fueling the vicarious joys of endless war.

The Post attempts to justify that disparity with their second answer, which perfectly captures the prevailing, and deeply warped, Beltway thinking: namely, escalating in Afghanistan is an absolute national necessity, while providing Americans with health care coverage is just a luxury that can wait:

All this assumes that defense and health care should be treated equally in the national budget. We would argue that they should not be . . . Universal health care, however desirable, is not "fundamental to the defense of our people." Nor is it a "necessity" that it be adopted this year: Mr. Obama chose to propose a massive new entitlement at a time of historic budget deficits. In contrast, Gen. McChrystal believes that if reinforcements are not sent to Afghanistan in the next year, the war may be lost, with catastrophic consequences for U.S. interests in South Asia. U.S. soldiers would continue to die, without the prospect of defeating the Taliban. And, as Mr. Obama put it, "if left unchecked, the Taliban insurgency will mean an even larger safe haven from which al-Qaeda would plot to kill more Americans."

Actually, a recent study from the Harvard Medical School and Cambridge Health Alliance documented that "nearly 45,000 annual deaths are associated with lack of health insurance" in America. Whatever the exact number, nobody doubts that lack of health insurance causes thousands of Americans to die every year. If you're Fred Hiatt and you already have health insurance, it's easy to dismiss those deaths as unimportant, "not fundamental," not a "necessity" to tend to any time soon. No matter your views on Obama's health care reform plan, does it really take any effort to see how warped that dismissive mentality is?

But it becomes so much worse when one considers what we're ostensibly going to do in Afghanistan as part of our venerated "counter-insurgency" mission. In an amazingly enlightening interview with Frontline, military expert Andrew Bacevich explains what that supposedly entails:

I think the best way to understand the term "counterinsurgency" is to understand what the U.S. Army and the Marine Corps today mean by that term. What they mean is an approach to warfare in which success is to be gained not by destroying the enemy but by securing the population.

The term "securing" here means not simply keeping the people safe, but providing for the people a series of services -- effective governance, economic development, education, the elimination of corruption, the protection of women's rights. That translates into an enormously ambitious project of nation building. . . .

John Nagl says that in effect we are engaged in a global counterinsurgency campaign. That's his description of the long war.

Now, think about it. If counterinsurgency, according to current doctrine, is all about securing the population, if securing the population implies not simply keeping them safe but providing people with good governance and economic development and education and so on, what then is the requirement of a global counterinsurgency campaign?

Are we called upon to keep ourselves safe? To prevent another 9/11? Are we called upon to secure the population of the entire globe? Given the success we've had thus far in securing the population in Iraq and in Afghanistan, does this idea make any sense whatsoever?

Can anybody possibly believe that the United States of America, ... facing a federal budget deficit of $1.8 trillion ... has the resources necessary to conduct a global counterinsurgency campaign? Over what? The next 20, 50, 80 years? I think [there] is something so preposterous about such proposals. I just find it baffling that they are treated with seriousness by supposedly serious people.

So according to The Washington Post, dropping bombs on, controlling and occupying Afghanistan -- all while simultaneously ensuring "effective governance, economic development, education, the elimination of corruption, the protection of women's rights" to Afghan citizens in Afghanistan -- is an absolutely vital necessity that must be done no matter the cost. But providing basic services (such as health care) to American citizens, in the U.S., is a secondary priority at best, something totally unnecessary that should wait for a few years or a couple decades until we can afford it and until our various wars are finished, if that ever happens. "U.S. interests in South Asia" are paramount; U.S. interests in the welfare of those in American cities, suburbs and rural areas are an afterthought.

As demented as that sounds, isn't that exactly the priority scheme we've adopted as a country? We're a nation that couldn't even manage to get clean drinking water to our own citizens who were dying in the middle of New Orleans. We have tens of thousands of people dying every year because they lack basic health care coverage. The rich-poor gap continues to expand to third-world levels. And The Post claims that war and "nation-building" in Afghanistan are crucial while health care for Americans is not because "wars, unlike entitlement programs, eventually come to an end." Except, as Bacevich points out, that's false:

Post-Vietnam, the officer corps was committed to the proposition that wars should be infrequent, that they should be fought only for the most vital interests, and that they should be fought in a way that would produce a quick and decisive outcome.

What we have today in my judgment is just the inverse of that. War has become a permanent condition.

Beltway elites have health insurance and thus the costs and suffering for those who don't are abstract, distant and irrelevant. Identically, with very rare exception, they and their families don't fight the wars they cheer on -- and don't even pay for them -- and thus get to enjoy all the pulsating benefits without any costs whatsoever. Adam Smith, all the way back in 1776, in An Inquiry into the Nature And Causes of the Wealth of Nations, described this Beltway attitude exactly:

In great empires the people who live in the capital, and in the provinces remote from the scene of action, feel, many of them, scarce any inconveniency from the war; but enjoy, at their ease, the amusement of reading in the newspapers the exploits of their own fleets and armies . . .

Lounging around in the editorial offices in the capital of a rapidly decaying empire, urging that more Americans be sent into endless war paid for with endless debt, while yawning and lazily waving away with boredom the hordes outside dying for lack of health care coverage, is one of the most repugnant images one can imagine. It's exactly what Adam Smith denounced. And it's exactly what our political and media elite are.

-- Glenn Greenwald