Friday, December 11, 2009

My Healthcare Post

I've been holding off doing anything on the subject of healthcare, even though it is the subject that just about every would-be pundit is spouting off about these days. It is really extremely technical stuff and frankly I don't feel particularly qualified to contribute much of value on the subject. Apparently, however, that hasn't stopped others from shooting their mouths off, and a lot of the nonsense going around about healthcare is incredibly misleading, both from pundits on the right and the left. So, I figured that I might as well join in.

First of all, I think it is helpful to draw the distinction between healthcare reform and health insurance reform. For the most part, the various pieces of legislation that pundits have been gnawing on for most of this year deal with health insurance reform, and not so much with healthcare reform. This limitation is not necessarily a bad thing, but it is important to remember this clarification of what we are talking about. Healthcare reform would address the quality and cost of healthcare, and to be sure, those are subjects that very much need to be addressed. I will say more about that towards the end of this post, but again, it bears repeating that in large part, this is not something being addressed by the current legislation.

That does not mean that the current legislation dealing with health insurance reform is unimportant. On the contrary, it is extremely important. Health insurance reform goes to the question of how Americans pay for healthcare. That is something that very much needs to be addressed. Indeed, I would argue that unless we deal with the problem of health insurance reform first - the way Americans pay for healthcare - we cannot deal with the more general problem of healthcare reform in a rational way.

In order to talk intelligently about health insurance reform, one first really ought to be able to talk intelligently about insurance. That is something right off the bat that has made me hesitate to try to pontificate on this subject. Talking about insurance inevitably gets you into subjects of "risk management" and actuarial tables and the like, at which point, I generally find my brain turning to mush. I don't know why my mind tends to recoil at the subject of insurance. I think I'm a reasonably intelligent person - I've even read Stephen Hawking's A Brief History of Time and understood a lot of it. Nevertheless, insurance eludes me. It always reminds me of the Seinfeld episode in which George was charged with the responsibility of doing a speech on "risk management" and somehow the notes for the speech got mixed up with Kenny Bania's comedy routine and hilarity ensued, but I digress.

What gave me the confidence to try to write something on the subject of health insurance reform was my recent reading of an excellent book on the subject, The Healing of America by T.R. Reid. Reid gives a pretty good rundown of the healthcare systems in various foreign countries, contrasting them with the shortcomings of the American system of paying for healthcare. I think this is a good way to approach the subject, because there are two salient facts that we do know about the American system of paying for healthcare: (1) the U.S. is the only advanced country that does not provide universal healthcare coverage; and (2) recent worldwide surveys rate the quality of healthcare in the U.S. very poorly, generally around #37 in the world. That statistic is somewhat misleading because it reflects an average, but that in itself is very revealing about what is wrong with the American system of paying for healthcare. If you have good health insurance in the U.S., you probably have access to excellent healthcare, among the best in the world, but the problem is that too many Americans can't pay for any access to healthcare, and that drags our average way down.

So, how do other countries pay for universal healthcare? There are three basic models analyzed in Reid's book, although I would argue (this isn't in Reid's book) that it is useful, particularly as it pertains to the U.S., to subdivide the third model into two sub-categories.

1. Socialized Medicine: This is the U.K. system, developed by Lord Beveridge and Aneurin Bevan and implemented by the Labour government following World War II. In this system, the government actually operates the healthcare system. The British government owns and operates hospitals and employs healthcare professionals to staff them (although most British physicians are private actors). The British National Health Service (NHS) is fully funded by the government out of tax revenues and its services are available to everyone free of charge.

2. Single Payer: This is the Canadian system, developed by Saskatchewan Premier Tommy Douglas (Kiefer Sutherland's grandfather) in the early 1960s. Unlike the British system, the Canadian healthcare system itself is privately owned and operated; there are private hospitals, clinics, etc., and doctors, nurses and other healthcare professionals are private actors. However, all healthcare costs, for everyone, are paid entirely by the government, financed out of tax revenues.

3. The Bismarck System: This is the German system (followed in variations by many other European countries), developed by Otto Von Bismarck in the 19th Century. In this system, all persons are required by law to have health insurance, and you may choose from any number of different private not-for-profit insurance funds to provide coverage (in Germany, there are over 200 of these "sickness funds"). The amount a person pays for coverage depends on their income level, which is implemented through tax adjustments, with taxes imposed on the rich and credits and subsidies available to the poor. If you don't like the coverage offered by any of the funds, you may opt out of the system and buy health insurance from a private for-profit company; but again, all persons are required to have some form of health insurance coverage.

As I said, I would also include a variation on this last system which Reid does not discuss, namely, the Dutch system. Like the Bismarck system, the Dutch system mandates that all persons have health insurance, but instead of using not-for-profit insurance funds, the Dutch system implements universal coverage through for-profit private insurance companies. The government maintains an intensive system of regulation over health insurance companies to prevent premiums from being excessive and to ensure that there is a high level of competition among the private health insurance companies. As in the Bismarck system, government subsidies are provided to the poor to pay for health insurance.

Reid applies these categories to the American system of paying for healthcare, and shows how these categories do in fact apply to various segments of the American population:

Category One - Socialized Medicine: In fact, one segment of the American population does receive socialized medicine, namely, veterans. The Veterans Administration owns and operates hospitals and staffs them with doctors, nurses, and other healthcare professionals who are employed directly by the Federal government. The VA operates a system that is every bit as much an example of pure socialized medicine as the British NHS, perhaps even more so.

Category Two - Single Payer: Senior citizens are covered by a single payer system, namely, Medicare. Notably, the Canadian single payer system is also known as "Medicare". In Canada, however, everyone is covered by Medicare, while in the U.S., Medicare is only available to senior citizens.

Category Three - Private Health Insurance: Most employed Americans are covered by private health insurance. Generally, this is provided as a benefit of employment. This system is encouraged by the tax laws, which make health insurance coverage tax deductible for the employer and non-taxable for the employee.

People falling into these three categories comprise about 84% of the American population, which of course leaves about 16% who have no coverage. This translates into roughly 40-45 million Americans without coverage. Those without coverage include employed persons whose employers do not provide health insurance; unemployed persons; persons who have "pre-existing" medical conditions and as a result are rejected for coverage by private insurance companies; and persons who for one reason or another choose not to purchase health insurance. This last group includes many young people who do not perceive catastrophic illness to be a significant threat and accordingly elect not to incur the cost of purchasing health insurance.

Before talking about different possible approaches to reform, it is helpful to think of this last group - Americans without coverage - as comprising a distinct fourth category. As one healthcare expert pointed out in a lecture I attended, we do have a form of "universal" healthcare coverage in America; after all, American cities do not look like a third-world country, with untended sick people dying in the streets. However, the manner in which the U.S. provides "universal" healthcare to people falling into Category Four is barbaric. America deals with this fourth category in a manner that is both extremely expensive and extremely ineffective as a means of providing healthcare services, which can be summarized as follows:

Category Four - Welfare, Charity and Emergency Rooms: Persons falling into Category Four lack the means of paying for "wellness" healthcare such as routine check-ups and regular doctor visits. However, if these persons are poor enough and sick enough, they will get some form of healthcare, generally paid for by various forms of welfare, primarily Medicaid, and frequently administered in hospital emergency rooms. This is a method of providing healthcare that is extraordinarily inefficient in that it is both extremely expensive and ineffective as a means of promoting good health. This is reflected in a particular statistic about the quality of American healthcare that I find to be extraordinarily damning. The rate of death from treatable illnesses is far higher in the U.S. than in any other even moderately advanced country. This is clearly a product of the fact that for persons falling into Category Four, the healthcare that they receive is not only too little, it is often too late.

I find it very helpful to use these four categories as a way of thinking about the nature of the problem of trying to reform the manner in which Americans pay for healthcare. This categorization is also very useful in understanding the political problems that are posed to attempts to reform health insurance, and the deficiencies in the approaches to reform of both the left and the right.

For the right, the deficiency in their approach to the problem is obvious. The right acts as though it either does not believe or simply does not care about the fact that Category Four exists at all. I find this attitude appalling and unacceptable. We cannot accept an America in which more than forty million Americans simply do not have any means of paying for decent healthcare. Indeed, as I discuss in more detail below, it seems clear to me that if we do not do something about Category Four now, the condition of persons falling into this category will soon deteriorate markedly, and in a few years, America may very well begin to resemble a third-world country in which we routinely expect to see bodies of the dead or dying strewn about the streets due to lack of medical attention.

The deficiency of the approach of the left is a bit more subtle. The left, to its credit, is very much aware of the existence of Category Four, and its goal is to eliminate Category Four by making access to quality healthcare a universal right. I absolutely join in that objective.

The problem with the point of the view of the left, I would submit, is that it does not pay enough attention to the needs and interests of Category Three, which consists of the overwhelming majority of American workers - and voters. For almost everyone on the left, the ideal means of achieving universal coverage would be to enact a single payer system. While most people on the left do recognize that this is not politically feasible, there is a tendency on the left to believe that this lack of political feasibility is solely due to the power of insurance company lobbyists. I think this is a mistake; in my view, the real reason why a single payer system is not politically feasible in the U.S. is because it would not be acceptable to most of the Americans who fall into Category Three.

It is helpful to step back and look at the history of how the U.S. came to have a system, unlike any other advanced country, in which most Americans' access to healthcare is financed not by the government, but by private health insurance obtained as a benefit of employment. This system did not come into being either because of a nefarious conspiracy perpetrated by private insurance companies, as some on the left believe, or because the free market dictated that private health insurance companies provide better services than government agencies do, as the right believes. Ironically, the American system of employment-based private health insurance actually came into being because of government interference in the marketplace. During World War II, the government imposed strict wage and price controls as a means of guaranteeing the smooth production of war materials. Labor was very scarce during the war, but employers were nonetheless barred from offering higher wages as a means of competing for the services of scarce workers. However, government wage and price controls permitted employers to offer benefits other than wages, such as health insurance, as a means of attracting employees. Thus, by the time World War II ended, the provision of health insurance as an added benefit of employment had become widespread and very popular with both employees and employers (as noted, the tax laws reinforced the attractiveness of employee health insurance). At the very time that the postwar U.K. was establishing the NHS, and most of continental Europe was adopting different versions of government-subsidized Bismarck-type health insurance schemes, there was relatively little enthusiasm in the U.S. for a government-financed system of universal healthcare.

For those Americans falling into Category Three, employment-based private health insurance continues to be quite popular. Surveys generally show that most Americans who do have private health insurance are relatively satisfied with their coverage. To be sure, Americans who have private health insurance are sufficiently satisfied with it that they become very nervous if they think that politicians are threatening to force them to relinquish their private insurance in favor of a government-run program; this is why the "Harry and Louise" ads and similar scare tactics have resonated with the American public and have successfully killed prior efforts at reform. And, as I will discuss below, I also believe that the preference for private health insurance as opposed to a single payer system is by no means irrational.

Nevertheless, the problem with a system that relies so heavily on private health insurance to pay for healthcare is that it leaves you with Category Four - a large segment of the population dependent upon welfare and charity to pay for even minimal levels of healthcare. Thus, the goal of health insurance reform ought to be to try to eliminate Category Four by folding Category Four into Category Three, using government subsidies and regulations of health insurance companies to deal with the costs entailed. This would produce something in the U.S. that resembles the Bismarck system, particularly as modified by the Dutch, while of course leaving socialized medicine in place for veterans (the VA) and single payer in place for senior citizens (Medicare).

The basic elements of what would be required to move Category Four into Category Three are fairly straight-forward. First, you need regulations requiring insurance companies to cover everybody, prohibiting denials of coverage based on pre-existing conditions and the like. Second, you need subsidies to enable the unemployed and other poor persons to be able to buy insurance. Third, you need to require most employers to provide health insurance as an employee benefit. Finally, as a sort of mopping-up device, you need an "individual mandate" requiring everyone to have health insurance, prohibiting "free riding" by those (mostly young persons) who are willing to gamble on the possibility that they will remain healthy and not need health insurance.

A lot of people have trouble understanding why you have to have the mandates - why can't we just require insurance companies to offer insurance to everyone who wants it regardless of pre-existing conditions and the like, but continue to allow people who are so inclined to choose to take the gamble that they will not need health insurance? The answer to this question lies in those nasty, arcane principles of "risk management" that have always made insurance such an opaque subject for me. I'll do my best to lay out the issues as I understand them.

The idea of "risk management" works as follows. The "product" that an insurance company sells is the right to receive a benefit upon the occurrence of a particular event; in the case of health insurance, that "event" is the need to see a doctor or possibly the need to receive some more extensive, and expensive, form of healthcare services such as a long-term stay in a hospital. The price that the insurance company charges for the product comes in the form of the premiums paid by insureds, and the amount of the premium depends upon a computation of the likelihood that the insurance company will have to pay out these benefits. This in turn gets you to those actuarial tables, which enable the insurance companies to compute the likelihood of an "event" occurring that will require the payment of benefits. "Risk management" is the process by which an insurance company minimizes the risk that it will have to pay out benefits relative to the amount of premiums paid by insureds. Successful risk management enables an insurance company to maximize its profitability, which of course is the raison d'etre of any private business.

There are two different ways in which risk management enables an insurance company to maximize its profitability. First, the insurance company can shrink its pool of insureds so as to eliminate those who present the greatest risk of being likely to claim entitlement to benefits. That is why health insurance companies want to deny coverage to persons having pre-existing conditions, because those persons present the greatest risks of being in need of benefits. There is, however, another way that an insurance company can use principles of risk management to enhance profitability. The insurance company can expand its pool of insureds, so that even though the insurance company is providing coverage to people who have a high likelihood of becoming entitled to receive benefits, that risk will be counterbalanced by the fact that the insurance company will be receiving premiums from a large number of insureds who have a very low likelihood of being entitled to receive benefits.

Thus, if, in order to get to universal coverage, Congress passes a law prohibiting insurance companies from denying coverage to persons with pre-existing conditions - the riskiest portion of the population from the perspective of health insurance companies - the inevitable result would be a huge increase in the premiums insurance companies would have to charge its customers; either that, or else a large number of insurance companies would be forced out of business. The way to avoid that is to expand the risk pool by mandating that all persons have health insurance, particularly those young, relatively healthy "free riders" who are unlikely to need much by way of benefits and whose premiums would therefore pay for the benefits to be provided to the folks with pre-existing conditions, who present the greatest risk of needing healthcare benefits.

This is the essence of virtually all of the health insurance reform proposals floating through Congress. It is also the essence of the Dutch variation on the Bismarck system. The Dutch system makes it possible to provide universal coverage through private for-profit health insurance companies by spreading the risks, thereby ensuring that everyone is covered and premiums are kept at manageable levels.

Before we all celebrate and proclaim "mission accomplished", it should be noted that there are some glitches that make it difficult for the U.S. simply to copy the Dutch system. As I said above, the Dutch system includes intensive governmental regulation of the health insurance industry so as to ensure that risks are truly spread out throughout the system and premiums are kept in check. In addition, the Dutch make sure that there is a high level of competition among private health insurance companies, again, so as to guarantee competitive pricing and competition in the packages of benefits that are offered to consumers. The U.S. currently lacks both of these features. Almost all regulation of the insurance industry is carried out at the state level, and there is very little by way of Federal insurance regulation. State insurance regulators tend to be pretty spotty. In some states, such as New York, state insurance regulators are known to be very active; in other states, however, such as Texas or the Dakotas, state insurance regulation is minimal to non-existent. In addition, the level of competition in the health insurance industry varies widely from state to state. Again, in some states such as New York, there is a good deal of competition among health insurance companies, but in a great many states, there is little if any competition, and single health insurance companies hold virtual monopolies on the business within their states.

The Republicans frequently argue that the solution to the problem of lack of competition is simply to allow consumers to buy health insurance across state lines. The problem with this suggestion is, again, the fact that insurance companies are largely regulated at the state level. If a consumer were to buy a health insurance policy from an out-of-state company, the consumer would effectively be buying a policy from an unregulated insurance company. The consumer would have no guarantee that the company in fact has sufficient capital to pay the benefits promised by the policy. It is a virtual certainty that if consumers were permitted to buy insurance across state lines under the current system, a great many consumers would wind up holding the bag in the form of worthless health insurance policies issued by unregulated insurance companies lacking sufficient capital to pay benefits.

The only way that permitting interstate insurance sales as a means of promoting competition would make sense would be if you had some sort of interstate compact among state insurance regulators to ensure the viability of the companies and the policies they sell on the interstate market, or better yet, if you had Federal regulation of the insurance industry - in other words, if you had something more like the Dutch system. In my opinion, that would be a very good thing, and it is probably the most likely direction in which the American system will evolve.

A "progressive" solution to the problem of lack of competition in the health insurance industry was suggested in 2007 by a political scientist at Berkeley (he is now at Yale) named Jacob Hacker, who originally proposed the idea of a "public option." Hacker proposed that this public option could be integrated into a system of universal mandates, so that consumers would have the "option" of buying into a Federal health insurance program such as Medicare as an alternative to buying private health insurance. The idea was that such a "public option" would guarantee the existence of competition and would thereby prevent private health insurance companies from raising premiums excessively.

Conservatives and lobbyists for health insurance companies pounced on Hacker's concept of the public option as nothing more than a backdoor way of implementing a single payer system. This argument is not without some force. A public program such as Medicare does not operate through the marketplace. Rather, a public program such as Medicare finances itself through tax revenues, and it is not forced to support itself by offering competitive services in the marketplace. In addition, a public program such as Medicare keeps its costs down by being able to dictate the reimbursement rates it will pay to healthcare service providers (doctors, hospitals, etc.) by using rates that are set by law, instead of rates that are negotiated in the marketplace. Conservatives argue that no private health insurance company could possibly compete with a public program such as Medicare on these terms, not because Medicare offers "better" or cheaper services, but because Medicare has the ability to finance itself through taxation and it can impose reimbursement rates on service providers by force of law - things that no private insurance company could possibly do. Thus, the argument goes, even though this "robust" public program would only be an "option" available to consumers as an alternative to private health insurance, the inevitable result of having such a "robust" public option would be that private health insurance premiums would go up because healthcare service providers would charge higher rates to privately-insured patients in order to offset the low reimbursement rates dictated by the public option; this, in turn, would inevitably cause consumers to choose the public option over private health insurance, thereby driving a lot of private insurance companies out of business and ultimately leading to a single payer system.

In order to counter these arguments, many Democrats, led by Senator Schumer, have backed off of the concept of the "robust" public option (i.e., a government program such as Medicare as an option available to healthcare consumers), and instead have proposed what they call a "level playing field" public option. Under this approach, the public option would not be financed by tax revenues and instead would be required to pay for itself out of the premiums it would be able to collect from consumers; in addition, the "level playing field" public option would not pay Medicare reimbursement rates and would instead negotiate reimbursement rates with service providers just like a private insurance company does. In short, the "level playing field" public option would be no different from any other insurance company, except that it would be owned and operated by the government, and the only function of the public option would be to guarantee some measure of competition so as to "keep private insurance companies honest."

Critics of the "level playing field" public option on both the left and the right argue that the proposal does not make a lot of sense. A public health insurance program is unlikely to do the sorts of things that private insurance companies do in order to hold down costs, such as engage in hardball negotiations with consumers over coverage issues and with service providers over reimbursement. Thus, it is argued that the "level playing field" public option will inevitably be at a competitive disadvantage vis a vis private insurance companies. Progressives argue that this means that the "level playing field" public option would not be an effective check on private insurance companies. Conservatives argue that Democrats would not stand by and allow the public option simply to close shop because of its inability to compete with private insurers, and Democrats would instead be unable to resist the temptation to "unlevel the playing field" by providing tax subsidies and other advantages to the public option; this, in turn, would again put us on the slippery slope to a single payer system.

Personally, the public option, in either the "robust" or the "level playing field" form, strikes me as an intriguing idea, and I don't see much down side in experimenting with it as part of an overall package of reforms to get us to universal coverage. On the other hand, I can also see the validity of many of the arguments that have been made against the various forms of public options that have been proposed. It seems to me that the issue of whether or not to have a public option has been blown way out of proportion. What is most important is the necessity of universal coverage, and we can achieve that with or without a public option - i.e., by imposing regulations that prohibit health insurers from denying coverage based on pre-existing conditions and other reasons, by regulating premiums, and by mandating that everyone have health insurance, with subsidies available to poor persons who cannot afford it. The Senate Finance Committee bill used these elements to achieve virtually universal coverage without a "public option" of any kind, "robust" or otherwise. Indeed, having a public option really does very little to enhance the ability of a reform package to achieve universal coverage; both the Senate Finance Committee bill, without a public option, and the House Bill, with a public option, achieve roughly the same results in reducing the number of uninsured.

Most people on the left are unsympathetic to the argument that a "robust" public option will undermine private health insurance companies and put us on the road to single payer. However, I believe that this attitude is mistaken, again, because it fails to pay attention to the very real reasons why people in Category Three like private health insurance and prefer it to a single payer system. To expand on this point, it is important to recognize the shortcomings of a single payer system, some of which are touched on in Reid's book. A single payer system functions by legal fiat, not through the marketplace. The amount that gets paid into the system depends on the amount of taxes that the government collects (Judge Learned Hand once referred to taxes as "forced exactions" and not "voluntary contributions"). The amount that gets paid out is set by reimbursement schedules that are fixed by laws and regulations, again, not by the market. The mechanism that a single payer system uses to reduce costs is to cut reimbursement rates, much to the dismay of healthcare service providers such as doctors, hospitals, etc. In the U.S., service providers regularly complain about the low reimbursement rates paid by the single payer component of the American healthcare system - i.e., Medicare (Category Two) - but in the U.S., service providers can compensate for low Medicare reimbursement rates by raising the rates charged to privately-insured patients. If private insurance companies were forced out of business and the U.S. system drifted towards a single payer system, service providers would be unable to do this. Low reimbursement rates would have other consequences, namely, it would lead to shortages of healthcare providers. This in turn would result in precisely the kinds of problems we see in single payer systems such as Canada, including long waiting times for medical services and strict government rationing of available medical care. Americans who are currently lucky enough to fall into Category Three would hardly view such developments as "reform."

This brings me back to what I said at the beginning of this post - there is a difference between healthcare reform and health insurance reform. Ultimately, the root of the problem lies in the fact that healthcare is very expensive, and it is only going to get more expensive in the coming years. In single payer systems or other government-run healthcare systems such as the U.K.'s NHS, the economic pressure resulting from rising healthcare costs is manifest in the form of shortages, waiting times, and rationed care. In the U.S., the consequence of rising costs is radical inequality, where the insured receive quality healthcare but the uninsured receive none at all. We cannot formulate a rational approach to healthcare reform in the U.S. until we address this fundamental reality - radical inequality - and that is why I believe that enacting health insurance reform and establishing universal coverage now are the top priorities, and the essential first steps towards real healthcare reform.

To be sure, the healthcare debate that has now been going on for almost a year has been very frustrating, often excruciating, and a lot of people would like to abandon reform efforts altogether. The right says that the endeavor to reform health insurance should be abandoned and that the sole focus should be on cutting costs. Some on the far left are also proposing that reform efforts be abandoned for now (I'm not sure why the left thinks that things will get better in the future) because of the apparent unwillingness of Senate moderates to accept any form of public option, arguing that without a public option, health insurance reform proposals amount to nothing more than a "giveaway" to health insurance companies - notwithstanding the fact that even the most conservative of the reform proposals on the table, the Senate Finance Committee bill, does in fact achieve something approximating universal coverage. I cannot say this too strongly: both of these positions are wrong, and they are worse than wrong - they are unconscionable.

Consider what would happen if health insurance reform were abandoned at this point: This would leave the current U.S. system intact, i.e., we would retain Categories One through Four. As I said, healthcare is likely to get even more expensive in the years ahead than it is today. Indeed, demographics are likely to result in breathtaking healthcare cost increases, as we Baby Boomers get older and sicker. How is Congress likely to deal with the inevitable pressures to make large cuts in the cost of healthcare? Categories One through Three all have a lot of political clout, and it is highly likely that politicians will do everything they possibly can to protect the interests of persons falling into those categories. Category Four, however, has no political clout. It seems unquestionable to me that a future Congress (one that would undoubtedly be dominated by Republicans if Democrats are stupid enough to bungle the current opportunity to implement real health insurance reform) would deal with rising healthcare costs by taking a meat axe to programs like Medicaid and other welfare programs for the very poor and the uninsured. Then the U.S. really would look like a third-world country or Dickensian London in which healthcare for the poor is entirely a matter of charity, if that. Maybe it's just me, but I don't want to live in that country.

There is an alternative: eliminate Category Four now by folding it into Category Three. Preserve the system of private health insurance that is popular with the many Americans fortunate enough to be covered by it, and use regulations, mandates and subsidies to make the system universal. Both the Senate Bill (without a public option) and the House Bill (with a public option) effectively move about 75% of the persons currently in Category Four into Category Three. We must not let the opportunity to do that slip away.

One final point that bears emphasis: what I have described is just the beginning of the process of reform, not the end. Some projects for future reforms include:

1. Implement better regulation of health insurance companies by establishing something at the Federal level like an SEC to oversee health insurers in order to prevent price-gouging on premiums and abusive practices on coverage decisions.

2. Get to work on real healthcare reform, in addition to health insurance reform. I will address one aspect of that subject which I actually know something about. Specifically, I believe that there ought to be bipartisan consensus on the need for tort reform to reduce the numbers of abusive medical malpractice suits. However, I think that a lot of the "tort reform" we have heard about in the past is misguided. Most tort reform has heretofore taken the form of caps on damage awards (e.g., the Texas system). Runaway awards are not really the problem. Relatively few malpractice cases actually go to trial, as most cases are settled before trial, and in reality, excessive awards by runaway juries are well-publicized but relatively rare occurrences. Arbitrary caps on damages can leave plaintiffs who suffered from true malpractice with inadequate compensation, while doing little to address the real deficiencies in the way our legal system handles medical malpractice suits.

The bigger problem is that there are simply too many malpractice claims and our legal system lacks effective means of weeding out frivolous claims. A reasonably smart plaintiff's lawyer can cobble together a medical malpractice claim that is good enough to survive a motion for summary judgment (not a very exacting standard) and then negotiate a settlement before the case goes to trial. Malpractice defense lawyers hired by malpractice insurers are often motivated to take the same approach, as they have no incentive to try to dispose of a case at an early stage of the litigation (i.e., before the defense lawyers have charged much in fees). The frequent scenario is that cases get settled "on the courthouse steps", just before trial but after a great deal of money has been spent on legal fees. In a rational system many of these cases should never have been brought at all - let alone become the basis for large legal expenses and substantial settlements.

There are a number of ways of dealing with these problems. Indeed, as part of governmental regulation of the health insurance industry, panels of medical experts can, and undoubtedly will, set forth guidelines on "best practices" in order to make determinations as to what kinds of medical procedures are appropriate for particular conditions, so as to delineate those procedures that warrant reimbursement. A physician who adheres to these "best practices" ought to be immune from a malpractice suit, provided that the physician did not act negligently in carrying out these practices. Such a rule would go a long way towards weeding out frivolous malpractice suits, thereby reducing the costs of medical malpractice insurance and also reducing the wasteful practice of "defensive medicine", i.e., wasteful and unnecessary medical procedures which are designed to provide a defense against a potential malpractice suit but which do nothing to promote the quality of healthcare.

The potential for healthcare reform is vast, and there are many competent professionals who know a lot more than I do about what ought to be done. There is, however, one thing I am certain of. The first thing that we need to do is to establish universal coverage. We have the opportunity to do it now, and we must seize that opportunity. When every American has access to quality healthcare, every American will also have a stake in promoting quality healthcare. That is a constituency that politicians cannot ignore.

Monday, December 7, 2009

Correspondence With Thomas Barnett

Thomas Barnett was good enough to post some comments I sent along to him concerning my views on imperialism and globalization.

Nice to get the feedback.

Wednesday, October 28, 2009

Short[er] Follow-Up On Afghanistan

I have a feeling that my last post on Afghanistan was a bit too long (and turgid) for most readers to wade through. I'm sorry about that, because I was really proud of it. I thought I did a pretty good job of tying together the history of the region and the current situation. If you have the time, I do hope you will read what I had to say.

My bottom line: I think that the US should continue its military operations in Afghanistan. My view is that US military operations in Afghanistan are necessary but not sufficient to bring about a resolution of the conflicts in both Afghanistan and Pakistan. Real long-term peace and stability, however, also requires a greater diplomatic effort by the US to involve the regional powers - India, China, Iran and Russia - in bringing about a resolution of the conflicts.

Here's the clincher on why I think we can't withdraw from Afghanistan anytime soon. Thomas Friedman had a column in today's New York Times proposing that the US begin withdrawing from Afghanistan. You can become pretty much of a foreign policy wizard simply by coming out in favor of the opposite of whatever Thomas Friedman proposes. The man's judgment (or lack thereof) is flawless - he is the George Costanza of pundits. President Obama should give Friedman a big office in the White House so that he can get his opinion on all major issues - and then do the opposite.

The New York Times does have a columnist who really knows what he is talking about on international affairs, Roger Cohen, but unfortunately you can generally only find him online and not in the print edition. Cohen's writings about Afghanistan have been right on the mark.

Someone with whom I don't usually agree, Henry Kissinger, has also written some very sensible stuff about Afghanistan. Consistent with what I suggested in my earlier post, Kissinger sees the involvement of the regional powers as essential to any resolution of the Afghanistan/Pakistan conflict.

Finally, it is important to emphasize that the involvement of the regional powers need not be military in nature; getting them involved economically in Afghanistan is even more important. Military strategist Robert Kaplan pointed out in a recent Times op-ed piece that Chinese companies have been seeking to develop mineral resources in Afghanistan.
Kaplan worries that this will lead to an enhancement of the Chinese "strategic" position in the world and a concomitant decline in the status of the American "empire" - he fears that the Chinese will drink America's milkshake. Nevertheless, Kaplan concedes that Chinese investment in Afghanistan will produce jobs for Afghans in industries other than growing opium poppies, as well as the development of infrastructure such as roads and pipelines running through Afghanistan connecting China to the Indian Ocean. Obviously, economic development in Afghanistan, one of the poorest countries on the planet, is the only thing that will ultimately bring peace. None of this economic development, however, can take place without some level of security. Chinese companies are not going to build roads and pipelines and set up mining operations if radical extremists in the Taliban and al Qaeda are going to blow them up and take Chinese business executives hostage. This is the positive, and necessary, contribution that can be made by continuing US military involvement in Afghanistan.

This is what globalization is all about, and it is the reason why Kaplan's concern obout the Chinese "strategic" position is so misplaced. If we think of US military endeavors in Afghanistan and elsewhere in the world as being driven by a desire to promote the "American Empire", then I will be the first one on the picket lines cheering for our failure. Imperialism and colonialism in any form, American or otherwise, are the great enemies of globalization. Multilateralism is the antidote. That's what FDR's "New Deal for the world" was all about, and as I have previously written, that is the essence of my ideal of "liberal patriotism".

So here, in a more abbreviated nutshell than I was able to set forth in my previous post, is my program for what I think President Obama should do in Afghanistan:

1. As I did emphasize in my previous post, Afghanistan is a multi-ethnic state, and the Pashtun are the largest ethnic group. The Pashtun are divided between Afghanistan and Pakistan (a legacy of British colonialism) and the Taliban, operating in both countries, is today probably the best organized force among the Pashtun. No resolution of the conflicts in Afghanistan and Pakistan can be achieved without the participation of the Pashtun, and that probably means the participation of at least some of the elements currently supporting the Taliban.

2. Right now, negotiation with the Taliban is impossible. The Taliban think they are winning. They think that the US has "post-Vietnam syndrome" and that popular opinion will force an immediate withdrawal of US forces. When you read stuff like Friedman's column today - which is rapidly becoming the "conventional wisdom" about Afghanistan - it is hard to disagree with that assessment. Moreover, the Taliban knows that once the US leaves Afghanistan, the Taliban will be able to resume its cozy relationship with the Pakistani military, as had been the case prior to 9/11. Accordingly, the leading forces among the Pashtun currently have no incentive to enter into negotiations towards a resolution of the conflicts in Afghanistan and Pakistan. And, as long as the Taliban thinks that it is going to win the conflict, it has no incentive to sever its ties with al Qaeda.

3. Therefore, it is essential that the US send the message that we are not leaving. This message needs to be heard loud and clear by the Taliban, al Qaeda, the Pakistani military, and all other factions in Afghanistan. I cannot think of a better way of sending this message than with the announcement of an increase in US troop levels. This is the only way of driving a wedge into the leadership of the Pashtun, and isolating Taliban extremists from other Pashtun tribal leaders. And, establishing a meaningful Pashtun leadership independent of Taliban extremists is the only way of resolving the conflicts in both Afghanistan and Pakistan.

4. Simultaneous with announcing an increase in US troop levels, President Obama should announce a major diplomatic initiative among all regional powers to propose a long-term resolution of the conflict. This initiative could take the form of a multinational peace conference to propose steps towards achieving long-term peace and stability in Afghanistan and Pakistan. Ideally, President Obama should announce all of this - the increase in US troop levels as well as the new diplomatic initiative - at a press conference surrounded by representatives not just of NATO and Pakistan, but also of India, China, Russia, Iran and possibly Turkey.

5. The multinational conference of regional powers would then propose a cease fire in both Afghanistan and Pakistan, to be followed by negotiations for the formation of a coalition government in Afghanistan. All factions in Afghanistan, potentially including the Taliban, would be invited to participate in these negotiations, provided that (1) they abide by the cease fire, and (2) they sever all ties with al Qaeda. A multinational peacekeeping force would enforce the terms of the cease fire.

I think it has a shot at working. My basic theme: we can't walk away, but we can't do it alone. I think President Obama is on the same wavelength.

Wednesday, September 23, 2009

Afghans Are Hounds and Rugs, But ...

Are they a people? This is the basic problem that plagues American policy in Afghanistan. Pundits and politicians who oppose continued US military involvement in Afghanistan argue that we should withdraw and let "the Afghans" take responsibility for their own governance and their own military security. Supporters of continued, or escalated, US military involvement argue that we need to fight on in order to defeat an insurgency that seeks to topple the "Afghan government."

The problem with both of these positions is that they assume that there is such a thing as "the Afghans" and that it is meaningful to talk about "Afghanistan" as though it were a genuine nation-state. I submit that this is incorrect. Rather, Afghanistan is a quintessential "fake state", that is, a nation that is not the product of the organic evolution of the history of the people living there, but instead, an artificial political entity that was cobbled together by outside imperial forces in order to serve their own ends.

Therein lies the fundamental conundrum facing America's involvement in Afghanistan. It is a conundrum that is likely to arise frequently throughout the world during the Twenty-First Century, particularly in Central Asia and Africa. The problems presented by fake states such as Afghanistan pose significant difficulties for traditional military strategies, including the counterinsurgency, or "COIN", strategy currently becoming popular among many younger officers in the Pentagon. Unfortunately, as I have ultimately concluded, as explained below, these very difficulties also make it virtually impossible for the US to end its military involvement in Afghanistan anytime in the near future. The key to US success, however, lies not in military strategy, whether it be the COIN strategy or something else, but in the strength of US commitment to the principle of multilateralism, and the willingness of the US to look to assistance from new allies, including China, India, and even Russia and Iran.

Let's first take a look at the question I posed at the outset of this post: who, or what, are "the Afghans"? The word "Afghan" is derived from the Persian name that was given to tribes of people who speak the Pashto language. These people generally refer to themselves as the "Pashtun". "Afghanistan" is basically a Persian word meaning "the land of the Afghans", i.e., the Pashtun. Right off the bat, you have to wonder about the legitimacy of a country the name of which is derived from the name that outsiders gave to the people living there.

But is Afghanistan really the land of the "Afghans", assuming that that term actually refers to the Pashtun. The Pashtun are the largest single ethnic group in Afghanistan, comprising about 40% of the country's total population, which is roughly 28 million. However, there are several other ethnic groups living in Afghanistan. Tajiks are about 27% of the population. Tajiks are ethnic Persians, but unlike Persians living in Iran who are Shiite Muslims, almost all Tajiks are Sunnis. There is, however, another Persian-speaking ethnic group in Afghanistan, the Hazara, who are Shiites, and they comprise about 10% of the population. The ethnic origins of the Hazara are somewhat mysterious, as many believe them to be descendants of the Mongolian army led by Genghis Khan. You also have groups who are of ethnic Turkic ancestry, primarily Uzbeks and Turkmen, who are also Sunni Muslims and together comprise about 15% of the total population. Finally, there is another ethnic group speaking a Persian dialect, the Baloch, who make up about 2% of the total population.

Thus, "Afghanistan" is a land made up of many peoples other than "Afghans", again, assuming that this term refers to the Pashtun. Now consider the flip-side of this fact: there are actually far more Pashtun (i.e., "Afghans") living outside of Afghanistan than there are living in Afghanistan. There are roughly 27 million Pashto speakers living in Pakistan, almost all of them in the North-West Frontier Province and the Federally Administrated Tribal Areas ("FATA") of Pakistan bordering on Afghanistan. This is more than double the number of the Pashtun living in Afghanistan. So again, one has to wonder how legitimate this country really is -- the majority of the people living in the "land of the Afghans" are not Afghans, and the majority of the Afghans actually live in another country.

There is a similar pattern with respect to the various other ethnic groups living in Afghanistan. It is almost axiomatic that there are large numbers of Tajiks, Turkmen, and Uzbeks living in the neighboring former Soviet republics of Tajikistan, Turkmenistan, and Uzbekistan. Similarly, most of the Baloch in the world live not in Afghanistan but in the neighboring province of Pakistan called, not surprisingly, Balochistan (sometimes spelled Baluchistan).

In short, as I said at the outset, Afghanistan is the quintessential "fake state." Its population is a hodgepodge of different ethnic groups having little in common with each other and no great desire to be part of the same country. On the contrary, all of these groups have far closer ties of language and culture to their country-folk living in countries adjacent to Afghanistan. These factors largely account for conflicts going on today in Afghanistan. Afghanistan exists as a country today only because there are lines on a map that say it exists. The people who drew those lines were not "the Afghans".

Map of Afghanistan showing ethnic groups,_by_district.svg

Today's nation-state of Afghanistan is a legacy of imperialism. Specifically, it is a product of two major imperial competitions: the "Great Game" of the Nineteenth Century and the Cold War of the Twentieth Century. These two historical events largely account for the dysfunctionality of today's Afghanistan.

The Great Game refers to the competition that took place during much of the Nineteenth Century between Russia and England for control of Central Asia. As the Russian Empire expanded into Central Asia, taking control of the areas that today comprise the former Soviet Republics in the region, England attempted to seize control of the area now known as Afghanistan to serve as a buffer against further Russian expansion, protecting British India as well as Persia, which although technically independent, was essentially a British protectorate. Thus, England fought two wars in Afghanistan in the Nineteenth Century (and a third in 1919). The Anglo-Afghan Wars became immortalized in popular culture through the poetry of Rudyard Kipling and the fictional character of Army Surgeon Dr. John Watson, whose service in Afghanistan left him with a lifelong limp and a trusty service revolver that he always brought along on his adventures with his housemate, Sherlock Holmes.

The general perception is that the Afghan Wars were a disaster for England, leading in large measure to the cliche that Afghanistan is the "graveyard of empires." While it is true that England never succeeded in conquering the territory that we today call "Afghanistan", and England lost a large number of lives in the effort, it is incorrect to view the results of the wars as nothing more than an exercise in futility from the British perspective. In 1893, a British diplomat, Mortimer Durand, negotiated a treaty whereby a large segment of Pashtun-occupied territory was annexed by England and incorporated into British India. The line of demarcation separating British India from the rest of the Afghan territory was known as the "Durand Line." Modern day Pakistan is essentially the western section of the old British India, and the border between Pakistan and Afghanistan that still exists today is none other than the Durand Line. This is why the bulk of the Pashtun population today lives not in Afghanistan but in Pakistan. It is also the reason why the border between Afghanistan and Pakistan is viewed as illegitimate by most of the Pashtun.

An independent kingdom of Afghanistan was established in the area of the modern state in the 1920s, following the conclusion of the third Anglo-Afghan War, which again ended with the Durand Line intact. Afghanistan thereafter receded from the attention of imperial powers, maintaining neutrality in World War II and through most of the Cold War.

In 1978, a pro-Soviet party, the People's Democratic Party of Afghanistan (PDPA) came to power. The PDPA attempted to implement a quasi-Marxist program based on secularism, land reform, and support for women's rights. The Carter Administration, led by the fervently anti-Soviet Zbigniew Brzezinski, attempted to capitalize upon the religious backlash that the policies of the PDPA had engendered by directing covert aid to Islamist opposition forces, generally known as the Mujahideen. In 1979, one of the leaders of the PDPA was assassinated and the Soviet Union launched an invasion of Afghanistan. The United States continued to fund the anti-Soviet Mujahideen, directing aid through Saudi Arabia and the Pakistani intelligence service, the ISI. In addition, Islamic fundamentalists from Saudi Arabia and other parts of the Muslim world flocked to Afghanistan to fight the Soviets alongside the Mujahideen. These groups became known as the "Afghan Arabs", and their charismatic leader was Osama Bin Laden, a member of a wealthy Saudi family and a fervent Wahhabi Muslim.

In 1989, the Soviet army prepared to withdraw from Afghanistan having suffered substantial casualties. Before withdrawing, Soviet President Gorbachev attempted to interest the US in a negotiated settlement that would have established a coalition government in Afghanistan, leaving the pro-Soviet President Mohammed Najibullah with a share of power. By this time, the first Bush Administration believed that "victory" had been achieved in Afghanistan and that the Soviets had no leverage to negotiate anything; accordingly, the US rejected the proposal for a coalition government. Gorbachev thereafter carried out the withdrawal of the Soviet troops without a negotiated settlement.

The Najibullah government collapsed in 1992 and Najibullah himself was executed. Najibullah was an ethnic Pashtun, and he was defeated by a coalition of non-Pashtun "warlords", primarily supported by Tajiks and Uzbeks. The warlords who overthrew Najibullah had little Pashtun support and Afghanistan essentially had no central government. Afghanistan thereupon entered into a state of civil war, not surprising given the country's vast ethnic diversity. Political power devolved upon the local warlords who drew allegiance based on local ethnic and tribal groupings. Without Cold War rivalries to motivate it to do anything, the US took no action to stabilize Afghanistan or to rebuild its shattered economy. Although Afghanistan degenerated into a state of bloody civil war and the rest of the world paid little attention, it is not correct to say that it was unconnected to the outside world. Afghanistan's connections, however, passed through two of globalization's darkest passages: drug trafficking and violent religious extremism.

While the cultivation of opium poppies has a long history in Afghanistan, the business took off during the Soviet invasion. The Mujahideen turned to opium production as a means of financing their resistance to the Soviets. Professor Alfred McCoy contends in his book The Politics of Heroin: CIA Complicity In The Global Drug Traffic (2003) that the CIA and the ISI helped to promote drug trafficking in Afghanistan in order to finance the Mujahideen. While that claim remains controversial, there is no question that the CIA and the ISI have a long history of ties to one of Afghanistan's most notorious druglords, Gulbuddin Hekmatyar. Hekmatyar was one of the principal players in the overthrow of the Najibullah government.

Drug trafficking in Afghanistan continued to expand following the departure of the Soviets, and today, Afghanistan is the world's largest producer of opium, as cultivation has declined in other parts of the world such as Southeast Asia and Turkey. There are several reasons why the trade has flourished in Afghanistan. The cultivation of opium poppies is a very labor-intensive process. It requires a very large number of poppies to produce a small quantity of opium. The process of extracting opium paste from poppies and drying it so that it can be converted into opium, and ultimately morphine and heroin, is laborious and time-consuming. Accordingly, the business of growing opium poppies tends to be attractive only in a subsistence economy where alternatives do not exist. Moreover, because the profitable cultivation of opium poppies requires the maintenance of vast fields of poppies, the crop is subject to ready eradication by law enforcement authorities. Thus, the opium trade thrives when two conditions are present - a subsistence economy and the absence of a strong government - and post-Soviet Afghanistan certainly had both of these characteristics. The flourishing opium trade in turn gave further fuel for the Afghan civil wars, not only by providing funding for the competing warlords but also by creating a shared incentive not to permit the establishment of a central government.

Religious extremism in Afghanistan was also in many ways a biproduct of the Soviet invasion. Although Afghanistan has long been a Muslim country and all ethnic groups tend to be conservative Muslims (about 90% Sunni), Afghanistan did not have a history of politicized Islamism prior to the Soviet invasion. The CIA and the ISI saw the promotion of Islamic fundamentalism as a way of stoking anti-communist sentiment. Saudi Arabia helped to finance madrasahs (religious schools) throughout Afghanistan, promoting the fundamentalist Wahhabist sect of Islam. As noted, Islamic fundamentalists led by Bin Laden and his followers had descended upon Afghanistan to aid the Mujahideen in fighting the Soviets.

By the mid 1990s, an extremist Islamist group led by Mullah Mohammed Omar began to assume a dominant position among the Pashtun tribes fighting in the post-Soviet Afghan civil wars. The group was a direct outgrowth of the madrasah movement, and its name, "Taliban", is the Pashto word for "students". By 1995, the Taliban had seized control of Kabul, the capital of Afghanistan, and it established the closest thing to a central government that Afghanistan had seen since the departure of the Soviets. The ascendancy of the Taliban among the Pashtun, however, did not put an end to the civil wars. On the contrary, the primacy of the Taliban incentivized the non-Pashtun opposition to coalesce and form the "Northern Alliance", made up of various competing warlords supported by groups of Tajiks, Uzbeks, and Hazara.

For reasons of ideology and practicality, Mullah Omar cultivated a close relationship with Bin Laden, who returned to Afghanistan after being expelled from Saudi Arabia and Sudan. Bin Laden became an implacable foe of the Saudi royal family following the first Gulf War - Bin Laden felt that he should be the one to oust the secular Saddam Hussein from Kuwait, not the American infidels - and he dedicated himself to a program of overthrowing the Saudi royal family and driving Americans and all non-Muslims not only out of the holy lands of the Middle East, but out of the entire Muslim world that made up the historical Caliphate. Bin Laden, who had now organized a loose global network of violent Islamist extremists known as "al Qaeda" (which means something like "the network" or "the database") headquartered in Afghanistan, directed a series of attacks against the Saudis and various western interests, culminating in the attacks of September 11, 2001. Mullah Omar refused to cooperate with American requests to apprehend Bin Laden.

In late 2001, the US launched an attack, primarily aerial, against the Taliban. With American air support, it was relatively easy for the ground forces of the Northern Alliance to drive the Taliban out of Kabul. In early 2002, Hamid Karzai, a veteran of the Soviet war who had acted as a CIA contact in funding the Mujahideen and one of the few prominent ethnic Pashtun who had supported the Northern Alliance against the Taliban, was installed as the new President of Afghanistan. By this time, the Bush Administration had bigger fish to fry, and it was already planning its invasion of Iraq. The Bush Administration committed relatively few ground troops to Afghanistan, and it was content to let the Northern Alliance carry out "mopping up" operations against the Taliban. A relatively small force of NATO "peacekeepers" was brought in to keep the peace. The Bush Administration also paid little attention to the state of the economy of Afghanistan, and the opium trade continued, and even expanded, as the economic backbone of the country (when it was in power, the Taliban had actually taken some steps to reduce opium production).

The Taliban, however, was not "mopped up" and there was no peace to keep. It is important to remember that the Taliban is not simply an Islamist extremist movement; more importantly, it is a Pashtun movement. The leadership of the Taliban, along with much of the leadership of al Qaeda (probably including Bin Laden), simply left "Afghanistan" and crossed the Durand Line and moved into the Pashtun areas of Pakistan, primarily in South Waziristan, part of Pakistan's FATA. As noted previously, Mortimer Durand's imaginary line had never meant very much to the Pashtun. Now ensconced in Pakistan with the leadership of al Qaeda, Mullah Omar and his followers proceeded to organize a new "branch" of the Taliban among the Pashtun living in Pakistan, where, as noted, most of the Pashtun (i.e. "Afghans") actually live.

Map of Pakistan Showing Provinces

The Taliban had long enjoyed a cozy relationship with the Pakistani government, particularly the ISI. Indeed, elements of the ISI looked with favor not only on the Taliban regime in Afghanistan, but also on the growing influence of the Taliban in the Pashtun regions of Pakistan. The Pakistani military is trapped in a mindset that views India as its sole enemy in the world, and many in the military and the ISI view a radicalized Pashtun population as shock-troops in what the Pakistani military sees as an inevitable war with India over Kashmir. Thus, although the US has ladled vast sums of money and military aid into Pakistan in the years since 9/11, little of it has gone towards fighting the Taliban. While much of the money has simply disappeared due to corruption, much of it has been diverted into military projects designed to strengthen Pakistan's position in a conflict with India. The last thing the Pakistani military has wanted to do is use the money to fight a radicalized Pashtun population, Pakistan's most enthusiastic supporters for a religious war with India.

By 2008, the Taliban had gained extensive influence throughout Pakistan's Pashtun regions in FATA and the Northwest Frontier Province, even moving into heavily-populated areas such as the Swat Valley and getting perilously close to Pakistan's capital city of Islamabad. In addition, a combination of factors enabled the Taliban to carry on a highly successful insurgency in Afghanistan. The booming opium trade provided the Taliban with a ready source of funding, and the ineffectiveness and corruption of the Karzai government fed a growing body of support for the Taliban among the Pashtun. American forces were inadequate to confront the Taliban, and most of the non-American and non-British NATO forces were peacekeepers ill-equipped to engage in deadly military confrontations. Moreover, the Taliban's success in Pakistan provided it with an easy avenue of escape when faced with opposition by American forces or Afghan forces loyal to the Karzai government - mostly non-Pashtun remnants of the Northern Alliance, poorly suited to fight in the Pashtun territory in which the Taliban thrives - by simply crossing over the Durand Line into sanctuaries in Waziristan. US and Karzai government forces could not attack the Taliban in Pakistan, and as noted, the Pakistani military had little interest in doing so on its own. The Taliban's growing influence in Pakistan strengthened the position of violent Islamist extremists throughout Pakistan, and not just among the Pashtun, as demonstrated by the assassination of Benazir Bhutto in December 2007 and even more dramatically by the massacre perpetrated by Pakistani extremists in Mumbai in November 2008.

President Obama ran on a platform of supporting a more aggressive pursuit of the war in Afghanistan and shifting US troops from Iraq to Afghanistan. In March 2009, that is precisely what President Obama did. President Obama discharged General David McKiernan as commander of NATO troops in Afghanistan and replaced him with General Stanley McChrystal, a proponent of counterinsurgency strategies who had worked closely with General David Petraeus in Iraq.

Since March, the situation has continued to deteriorate in Afghanistan. The bungled and almost certainly fraudulent election of August 2009 raises serious doubts about the legitimacy and efficacy of the Karzai government. In many ways, Karzai has always been the American-supported token Pashtun in what is really a non-Pashtun Northern Alliance government; accordingly, Karzai's lack of electoral support is not surprising. The Taliban has continued to press its military advantage and support among many Pashtun tribes, leading General McChrystal to recommend a further increase in US troop levels, absent which a Taliban military victory in the near future appears likely, at least according to General McChrystal.

The prospect of further US military escalation in Afghanistan has given rise to a domestic political backlash, particularly among Democratic Party liberals. Senator Feingold has called for a timetable for the withdrawal of all US troops from Afghanistan. The more moderate Senator Levin, Chair of the Senate Armed Services Committee, has come out in opposition to any further increase in the level of US troops. There are rumors that Vice President Biden has counseled President Obama to reject General McChrystal's recommendation for additional troops, and instead begin a withdrawal of US ground troops and a strategic shift towards a more limited objective of using airpower to target al Qaeda outposts. President Obama has stated that he is considering all options, making it clear that he is not going to be rushed into making any decisions about his future course of action in Afghanistan.

Objections to continued US involvement in Afghanistan have been even stronger in the liberal media. NY Times columnist Bob Herbert has written strongly and repeatedly in favor of a speedy withdrawal of US troops from Afghanistan. Liberal blogs have been virtually unanimous in opposing US involvement. Andrew Sullivan, whose current ideology is somewhat unclear - he is an openly gay, Catholic, self-proclaimed conservative who aggressively supported the Iraq War but turned against it and endorsed Obama - has veered beween strongly favoring withdrawal, to arguing in favor of "muddling through" for the time being.

A common theme that runs through virtually everything that is said or written in favor of a prompt withdrawal of US troops from Afghanistan, is that it is a "quagmire" and "another Vietnam." However, there are few relevant similarities between the conflicts in Afghanistan and Vietnam. Vietnam was primarily a "proxy war", played out against the backdrop of the Cold War in which the combatants were serving as stand-ins for the rival great powers. There is no such situation in the world today. On the contrary, all of today's great powers share identical interests with the US in Afghanistan: eliminating instability in Central Asia and preventing all of the externalities that flow from a failed state, such as terrorism, refugees, drug trafficking, and potentially even ethnic cleansing and genocide. It should also be emphasized that the Vietnam War can only be understood in terms of its role in the death throes of European colonialism. The adversary in Vietnam - the movement led by Ho Chi Minh - was a national liberation movement that successfully defeated one colonial power, France (and to a large extent, another would-be colonizer, Japan), and viewed the US merely as another colonial power seeking to take control of the country away from the Vietnamese. This perception of the US role in Vietnam was not without basis, and more than anything else, it was the US failure to understand that the Vietnamese viewed us as colonialists that doomed our involvement. Again, nothing comparable to that is involved in Afghanistan.

This brings up a second theme often asserted by proponents of US withdrawal, namely, the refrain that Afghanistan is the "graveyard of empires", as demonstrated by the failures of England and Russia. However, it is worth remembering that the objectives of the British and the Russians in Afghanistan were unabashedly colonial - they wanted to conquer it and make it part of their empires. If that were the US objective in Afghanistan, I would certainly agree that we would fail and properly so. However, even the most confirmed devotee of Noam Chomsky would have a hard time making the case that the US is trying to colonize Afghanistan. Unlike Iraq, Afghanistan has no oil or virtually any other natural resources of any great value (although there may well be significant untapped mineral resources in Afghanistan). Indeed, that is one of Afghanistan's major problems, and the reason why it is having trouble building an economy based on anything other than opium. It seems clear to me that the US has no ulterior colonial ambitions in Afghanistan, and that our objectives in pursuing this conflict are exactly what we say they are: preventing Afghanistan and the neighboring Pashtun areas of Pakistan from serving as a safe haven for al Qaeda, as was the case on 9/11.

Although the military situation has deteriorated in Afghanistan, there has been some encouraging news from Pakistan. There are signs that the Pakistani military has finally begun to shift its priorities away from preparation for a war with India, and to pursue violent extremists such as the Taliban in FATA with real vigor. These efforts by the Pakistanis have been aided immensely by US missile strikes, as demonstrated by the killing on August 5 of the leader of Pakistani Taliban, Baitullah Mehsud, an odious fellow with close ties to Mullah Omar and Bin Laden. As the Pakistani military has gradually become more serious about pursuing violent extremists such as the Taliban, there has also been a noticeable improvement in India/Pakistan relations, albeit still a long way from anything that might constitute a breakthrough. There can be little doubt that all of this would change in the event of a US withdrawal from Afghanistan, and the Pakistani military would undoubtedly again cozy up to the Taliban.

Instead of looking to Vietnam for historical analogies, I would suggest that a far more apt analogy is the conflict in the Balkans in the 1990s. Like Afghanistan, the former Yugoslavia was a "fake state" that was created not by the people living there, but by outsiders seeking to reconcile old imperial interests in the wake of World War I. Like Afghanistan, Yugoslavia had deteriorated into a state of civil war and there was essentially no central government. And most importantly, like Afghanistan, the warring ethnic groups in the former Yugoslavia had compatriots in neighboring states, and the ongoing Yugoslav civil war threatened to spread conflict throughout the region.

While the situation in the former Yugoslavia today is far from perfect, it is pretty good. Most people on both the left and the right would agree that the American military intervention in the Balkans in the 1990s was a success. I opposed military intervention at the time, but I readily admit now that I was wrong, and hopefully, I learned something from my mistake. (Actually, I didn't so much oppose American involvement in the Balkans, as I believed that the US should do more to act in concert with Russia rather than Western Europe; a pretty good idea in fact, just a few years ahead of its time). What we as a country should have learned from the experience in the Balkans are some of the parameters as to how and when US military force can be used effectively in dealing with Twenty-First Century conflicts. US military intervention in the former Yugoslavia was a necessary but not sufficient condition for a resolution of the conflict. US military action in the Balkans succeeded not simply because of the military strategy we followed, but because we were successful in making the conflict a matter of regional importance. Virtually all of the countries of Europe cooperated with the US in resolving the conflict, and most importantly, the cooperation provided by European countries was not limited to military assistance. In addition to providing peacekeeping forces in the former Yugoslav republics, European governments, and perhaps even more importantly European businesses, actively worked to build an economic infrastructure that would enable the former Yugoslavia to become integrated into the European community. That is essentially the "success story" that has been taking place in the Balkans in recent years (the current economic crisis has presented a bit of a speed bump in that process).

These lessons are directly applicable to Afghanistan. The key to success in Afghanistan is to stop viewing the conflict as simply an "American problem", and to begin addressing it as an enormous problem for the entire region of South-Central Asia. The countries that are most directly affected by the conflict in Afghanistan are those in the region: India (and of course Pakistan), China, Russia, and Iran. The impact on India and Pakistan of a US withdrawal and a Taliban victory has already been pointed out. Afghan drug trafficking has a huge impact on the countries of the region. Much of the Afghan heroin flows into Russia, which is now believed to have the world's largest population of heroin addicts.,0,2349140.story A great deal of Afghan heroin also flows into Iran, which has also long had a major problem with heroin addiction, leading the Iranian government to begin assisting the US in trying to eradicate Afghan drug networks.

The ethnic conflicts in Afghanistan also play a crucial role in destabilizing the region. The consequence of a US withdrawal will not simply be a Taliban victory, it will likely be a resumption of the Afghan civil war that had been ongoing since the end of the Soviet invasion. Again, it bears emphasis that the Taliban is essentially a Pashtun movement, and the Pashtun are only 40% of the population. The ethnic groups that make up the other 60% of Afghanistan would undoubtedly oppose the Taliban, as they did by forming the Northern Alliance. These ethnic groups have country-folk in the neighboring former Soviet republics and in Iran, and it is likely that the conflict would spread to these countries. The governments of the former Soviet republics are already of dubious stability, and they could readily be challenged by violent Islamist movements. Ethnic conflicts in Afghanistan could even embroil China, as the Muslim Uyghurs of the Chinese province of Xinjiang (which also borders on a small piece of Afghanistan) are ethnically and culturally related to some of the Turkic ethnic groups of Afghanistan, and growing militancy among Uyghur separatists is already a matter of considerable concern to the Chinese government.

Whenever any suggestion is made that the US should look to other countries to take a more active role in Afghanistan, the suggestion almost invariably refers to America's "allies" in NATO. However, it is unrealistic to think that most European countries will be willing to make any more significant military commitment to Afghanistan other than by supplying peacekeeping troops, and that is of limited utility until there is a peace to keep. A far more fruitful source of allies is in the immediate region, namely, China, India, and even Iran and Russia. Notably, General McChrystal has recently pointed out that Iran is actually playing a very positive role in using its influence in Afghanistan to assist the US. In all of the hubub about Iran's nuclear program, the media seems to have missed General McChrystal's statement that Iran may be one of our most valuable allies in Afghanistan. There is no reason why China and India cannot also be encouraged to take a more active role in assisting the US in the conflict. And while the prospect of another Russian incursion into Afghanistan probably sounds pretty unattractive to everyone - to the Russians most of all - Russia can nevertheless provide other forms of assistance, primarily through their relationships with the former Soviet republics. Moreover, as in the case of the conflict in the Balkans, assistance by the regional powers can include economic aid as well as military assistance. In particular, Chinese and Indian businesses have recently shown themselves to be quite adept at developing natural resources in some of the most remote countries of Africa. There is no reason why these skills can't be applied to the development of Afghanistan's significant untapped mineral wealth. This can be the key to building an economic infrastructure in Afghanistan that is essential to any prospect for peace.

I am not a military expert, and I do not have an opinion as to the correctness of General McChrystal's recommendation as to the need for increased US troop levels. What I do know, however, is that aggressive American diplomacy to get the other powers in the region more involved is just as important as military strategy to achieve success in Afghanistan. As in the Balkans, US military involvement is necessary but not sufficient to resolve the Afghanistan conflict. Fortunately, President Obama and Secretary of State Clinton made a wise choice for their point-person in the region. Richard Holbrooke is not only perhaps America's most experienced diplomat, he is the person who displayed considerable diplomatic skills in dealing with the conflicts in the former Yugoslavia. We need him to apply a similar approach here.

It is likely that the country of Afghanistan in its current form will cease to exist over the next few years. There are many possible scenarios as to what may happen. Like the former Yugoslavia, Afghanistan could simply break up into several separate countries based on the ethnic divisions in the country. It is also possible that the different ethnic groups could not simply seek to break away, but could also seek to unite with their country-folk in neighboring countries (Uzbekistan, Tajikistan, etc.). This could be particularly problematic as it pertains to Pakistan, which itself is, in many respects, a "fake state". The Afghan Pashtun could seek to join with the Pashtun in FATA, or the Afghan Baloch could seek to unite with secessionists in the Pakistani province of Balochistan. Instability in Balochistan is one of those sleeper issues that could suddenly burst onto everyone's radar screen in the next few years. Balochistan is geographically the largest province of Pakistan, but it is very sparsely populated. It is a mountainous region that has lots of nooks and crannies that provide ideal hiding places for terrorists, and it is believed that Mullah Omar has now moved to Balochistan since Pakistan has stepped up its anti-Taliban activities in FATA. The Persian-related Baloch have few ties of language and culture to the other peoples of Pakistan, although there is a substantial Pashtun minority in Balochistan. The Baloch often resent the "Indians" (i.e., Punjabis and Sindhis) who dominate the Pakistani government, and there is an active secessionist movement. While radical Islamism has never held much sway in Balochistan, and its secessionist movements have largely been secular and nationalistic in character, that could all change with the growing influence of the Taliban, and al Qaeda, in the province.

[An aside: A number of years ago, I saw a bumper sticker on a New York City taxi reading, "India Out of Baluchistan!" I had no idea what this meant, as I had no clue where Baluchistan was. After looking it up in an atlas, I was still at a loss because it did not seem as though India was in Balochistan, and hence cannot get "out", since Balochistan does not border on India and it is on the far southwestern part of Pakistan, bordering Iran. Ultimately, I figured out that there are two possible interpretations of the bumper sticker. "India" is the term that Balochis use to refer to the dominant parts of Pakistan, namely Punjab and Sindh, so the cab driver could have been a Balochi separatist. On the other hand, Pakistan has often accused India of fomenting secessionism in Balochistan, so the cab driver could have been a Pakistani protesting against Indian meddling in the Pakistani province of Balochistan. I love the kinds of education you get just by living in New York.]

On the other hand, it is conceivable that notwithstanding its ethnic diversity and the various secessionist forces at work, Afghanistan could continue to exist as a single sovereign state, albeit in a highly decentralized federated form. Managing these changes in a way that minimizes bloodshed and instability throughout the region will pose significant military and diplomatic challenges for the US. Richard Holbrooke may well be the only person in the world with relevant experience in handling such problems.

Many Americans will continue to question why the US should be expending lives and treasure in Afghanistan. It is difficult for most Americans to see how the conflict in Afghanistan has an immediate impact on America's security. Opponents of continued US military action argue that we can better defend ourselves against al Qaeda by strengthening homeland security. Andrew Bacevich, a sharp critic of US military involvement in the world who is particularly skeptical of COIN strategies, proposes prompt withdrawal from Afghanistan and a shift to a "containment" strategy for dealing with Islamist radicals. But in today's world of globalization, national security cannot be achieved simply by closing our borders. Global interconnectedness has many, many positive aspects, but it also gives rise to global dangers. The opium produced in Afghanistan's poppy fields flows directly into the shooting galleries of America's inner cities. A group of religious fanatics given sanctuary by the government of Afghanistan can plot to cause the deaths of thousands in New York and Washington. [And, as I observe above, even passions about conflicts in a place as far away as Balochistan can find their way onto the bumpers of New York City taxis.] The unfortunate reality is that opposition to all wars is not a viable policy in today's world. As Barack Obama accurately stated in articulating his opposition to the Iraq War back in 2002, we cannot oppose all wars, only dumb wars. Afghanistan is not a dumb war. We have to build better alliances with the great powers in the region, and it would be dumb for the US to fight this war alone, but approached correctly as an exercise in multilateralism, American military involvement can be an indispensable component to bringing about a favorable resolution in Afghanistan.

Addressing the conflict in Afghanistan will not only pose a test to President Obama's diplomatic skills, it will require the application of the full range of his formidable political skills. President Obama must present the case for American military involvement to the American public rationally but forcefully. President Obama is up against two strains in American attitudes about foreign policy that pose significant obstacles to a sound policy in Afghanistan. These strains are unilateralism and isolationism. As I have argued before, these strains are in many ways two sides of the same coin. Americans have a tendency to believe that we should always act alone in international affairs (the cowboy mindset), and if we can't do whatever we want to do by ourselves, we should not try to do it at all. President Obama must persuade the American people that this attitude is simply not a viable one in Afghanistan, or indeed, virtually anywhere else in today's world. We cannot walk away, but we cannot do it alone. And we must learn to think about the world in a new way. The Twenty-First Century is not a Euro-American world. To thrive in this world, Americans must learn to think about acting in concert with people who may seem different from us - not just the Indians, but the Chinese, the Russians and even the Iranians.

Afghanistan is probably just the beginning. The scenario now playing itself out in the Afghanistan conflict is likely to be repeated many times in the decades ahead, primarily in Africa, which is chock full of "fake states" left by European colonialists. America will not be able to avoid becoming involved in these conflicts; nor should we, at least, not if we care about stopping things like famine and genocide. Acceptance of multilateralism, and a willingness to look beyond our historical alliances in Europe for new partners, will be the key to our success.

Finally, a note on sources. I highly recommend the work of Pakistani writer Ahmed Rashid. He has an excellent piece in the current edition of The New York Review of Books updating the situation in Afghanistan. Anyone interested in digging deeper to get an understanding of the region should read Rashid's outstanding trilogy: Taliban: Militant Islam, Oil and Fundamentalism in Central Asia (2000), Jihad: The Rise of Militant Islam in Central Asia (2002), and Descent Into Chaos (2008).

As always, I also recommend the writings of Thomas P.M. Barnett, whose writings on Afghanistan, as on just about every other global issue, are among the best things out there.

Wednesday, August 26, 2009

Reclaiming Liberal Patriotism II

Without a past we are lost. Without a future we are doomed.

I found myself close to tears most of this morning. It surprises me. I have never been particularly taken by "the Kennedy mystique." I campaigned for Gene McCarthy in '68. Things got a bit heated during the primaries, and some of us didn't care for RFK that much. Still, I remember being unable to sleep on the horrible night of the California primary.

I felt some of the same things this morning.

I think of my personal recollections of Ted Kennedy. I remember seeing him at an airport once. It was around the time of the Bork fight, and I shook his hand to congratulate him on the good work he was doing. He looked so energetic, so confident.

I remember going to an Obama rally in New Jersey just before Super Tuesday. My daughter, who had never expressed much interest in politics before but was drawn to Obama, was the one who got me to go along. I ran into some people I had known from Northern New Jersey from the McGovern campaign. Ted Kennedy was there. He looked a lot smaller and more frail compared to the way he looked when I saw him at the airport twenty years earlier. But he still seemed to have the same confidence and energy. His speech was beautiful. So was Obama's. So was Cory Booker's. The past, the present, the future.

All my life, I've loved the study of history, almost to the point of obsession. I think about it a lot, American history in particular. There's a lot not to like about American history. I'm not particularly a fan of two guys who are Democratic Party icons, Jackson and Jefferson. I think they were hypocrites. Somehow, though, those hypocrites managed to let some very subversive words sneak into the fabric of our country:

"We hold these truths to be self-evident, that all men [sic] are created equal ..."

Much as the forces of reaction have tried to wipe them out over the years, those words are still there. They have inspired greatness throughout our country's history. Greatness on the part of figures in the establishment, like Lincoln and FDR. Greatness on the part of figures outside of the establishment like Frederick Douglass, Ella Baker, and Harvey Milk. Greatness on the part of a few outsiders who worked their way into the establishment, like Louis Brandeis and Thurgood Marshall. It's what I think of as liberal patriotism.

It's been hard for liberals to be patriotic during my lifetime. We've gone through the Cold War, Vietnam, the Kennedy assassinations, the assassinations of Martin Luther King and Malcolm X, Watergate, Iran-Contra, the Clarence Thomas hearings, the Clinton impeachment, the election of 2000, the Bush-Cheney reign. Torture as national policy - and Cheney brags about it.

Is there any room for liberal patriotism? That's why I got teary this morning. Because, throughout all of those years there have been the Kennedys. Perhaps, at times, they have been hypocrites, as other Democratic Party icons have been. Robert Kennedy worked for Joe McCarthy. John Kennedy did not say no to the Bay of Pigs.

But over the years they have also been the voices of liberal patriotism. They have been a bridge between what has been great in our past and what can be great in our future. JFK challenged us, literally, to reach for the moon, and we saw Neil Armstrong take his small step. RFK told us that when dreaming of things that never were, we should say "Why not?", and we saw the civil rights revolution become the law of the land. Teddy Kennedy told us, several times, that the dream would live on, and we saw America again became a beacon of hope for millions of immigrants.

Teddy Kennedy also told us that healthcare for all Americans is an unalienable right. How fitting, how striking it is that his life was brought to an end at this moment in our history. I'm starting to tear up again.

I have sensed some darkness in the liberal soul over the past few weeks. There has been defeatism. Liberals seem to be getting "wee-weed up" (I just love that phrase). There is a lot a cynicism; we expect Obama to be a sell-out, a disappointment. Lord knows we have plenty of reasons to be cynical. We hear that passing healthcare reform is just impossible. And the more we hear that, the broader the wolfish grin on the faces of the forces of reaction becomes.

Is it really that hard? Is it such a big thing to say that every American has a fundamental right to a guarantee of decent healthcare? I will not accept for an instant the suggestion that we cannot afford it. Even through economic crisis we are still the wealthiest country in the world, indeed, in the history of the world. I do not begrudge great wealth to people who have worked hard to earn it. But those who have truly earned their wealth are those who understand that they must bear great responsibility to those less fortunate. I think Teddy Kennedy understood that, perhaps better than anyone.

The simple answer lies in that subversive phrase woven into the fabric of our country, for all of us are truly created equal. No one of us has a greater right to lead a healthy life than any other.

I salute Senator Kennedy for all of his service to our country. Let us honor his life by reclaiming liberal patriotism.

I cannot wait for the day when President Obama signs the Edward M. Kennedy Healthcare Reform Act of 2009 into law.

Friday, July 3, 2009

Reclaiming Liberal Patriotism

On November 4, 2008, I fell in love. I fell in love with the United States of America.

As I may have mentioned on other posts, I am part of the baby-boom generation, born in the early 1950s. I hid under my desk in elementary school during the Cuban Missile Crisis while my teacher casually mentioned that an H-bomb dropped on the Empire State Building would melt steel in Hackensack (our school was a lot closer to the Empire State Building than it was to Hackensack). I went to college in the early 1970s and learned about what had happened to people like Mossadeq, Juan Bosch and Allende. I watched the assassinations, marched in antiwar rallies (Vietnam and later Iraq), lived through Watergate, Iran-Contra, the Clarence Thomas hearings, the Clinton impeachment, the 2000 election and you-know-who's Presidency that came after that. It often occurred to me that Noam Chomsky seemed to be making some good points about the evil America had perpetrated in the world.

Then came November 4, 2008. I spent the day volunteering as a Democratic legal observer at a polling place in a blue-collar district near Scranton, Pennsylvania. There wasn't much to observe. Everything went very smoothly, very peacefully. I would say that 90+% of the voters appeared to be white, working-class people.

That night I came home with my family, and was moved to tears by the results of the election. I happened to go online to see what the results had been in the district where I had been working as a poll watcher. Obama got more than two-thirds of the vote.

That was the United States of America I fell in love with. It was the same United States of America that had been there all my life, but I don't think I fully appreciated it before. Did America change or did I? Probably a little bit of both.

I have been reading a great deal about FDR's Presidency lately. My wife, son and I always make it a point to attend the annual Reading Festival at the FDR Library in Hyde Park, NY (our daughter joined us this year, my sister-in-law and her husband joined us last year). I recommend it highly.

In particular, I have become fascinated by FDR's foreign policy and his vision for America's role in the postwar world. A couple of years ago, one of the speakers in Hyde Park was Elizabeth Borgwardt, whose outstanding book, A New Deal For The World, was a real eye-opener. This year there were some excellent presentations on FDR's foreign policy by David Woolner, co-author of FDR's World, and by Christopher O'Sullivan, author of a new biography of Sumner Welles, Under Secretary of State during World War II and an influential architect of many of FDR's policies during the war.

FDR's vision of America's role in the world was best expressed in his incredibly moving "Four Freedoms" speech, namely, the belief that America must dedicate itself to the promotion and protection of freedom of speech, freedom of religion, freedom from want, and freedom from fear. Most importantly, FDR emphasized that these freedoms are the birthright of every person in the world, not just Americans. The concept was, and is, revolutionary. One person who was inspired by FDR's speech was an aspiring young South African lawyer named Nelson Mandela.

FDR's vision of the postwar world was more than just pie-in-the sky platitudes. FDR's thinking specifically differed from Wilsonian idealism in that it attempted to find grounding not just in theoretical structures and diplomatic organizations, but in the practicalities of real life. In particular, FDR understood that economic liberalism - a New Deal for the world - was essential to the implementation of his ideas. In a way, FDR's concept of America's role in the postwar world could be summed up as Wilson plus Keynes. FDR's vision stood on three pillars: free trade, anti-colonialism, and multilateralism.

There was also a fourth pillar underlying FDR's program having to do with the domestic politics of the US. FDR was committed to bipartisan consensus as the basis for achieving popular support for his program. It was not just FDR's war cabinet that was decidedly bipartisan. FDR recruited prominent Republicans such as Arthur Vandenberg to help implement his program for the postwar world. In other words, FDR's vision was not distinctly Democratic or Republican - it was American.

As I have studied FDR's vision of America's role in the world, it occurred to me that it reminds me a lot of the America I fell in love with on November 4, 2008. How could I have missed it for most of my life?

The Cold War did a great deal to undermine FDR's dream of a new world order predicated on the implementation of the Four Freedoms. The Cold War in turn had an enormous, and very negative, impact on US domestic politics. What had been the isolationism that had destroyed Wilson's dreams for a system of world peace after World War I, morphed into the McCarthyism and fanatical anti-communism that destroyed any hope for either bipartisanship in domestic politics or multilateral cooperation in international affairs. Indeed, David Woolner commented in his recent talk that the American ideological strain that had fought Wilson was never truly isolationist, but is more accurately described as unilateralist. What Wilson's opponents preyed upon in order to shoot down the League of Nations treaty was not so much an American desire to be isolated from the rest of the world, but a desire to preserve America's freedom to act unilaterally, based upon a suspicion of other countries and an unwillingness to commit the US to act in a cooperative fashion with the rest of the world.

Unilateralism was what made America's behavior so objectionable in the post-World War II era. When America becomes unilateralist, it can become very ugly. That is the America I protested against for its unilateral acts of aggression in Vietnam and Iraq.

Just as the Cold War opened the floodgates to American unilateralism under the guise of anti-communism, so too did it divert the US from FDR's vision of America as a bastion of anti-colonialism. Vietnam was the clearest manifestation of this. The US committed itself to the restoration of French rule in Indochina, even though the French had sided with the Japanese during World War II and Ho Chi Minh had carried on a guerrilla war against both the Japanese and the French. Woolner's book suggests that although the record is not clear on the point, FDR, had he lived, might well have pushed for a stronger anti-French position in post-war Indochina. No matter - Ho Chi Minh was a communist and in the mindset of the Cold War, we had to defeat him. Anti-colonialism got put on the back burner. When the Vietnamese defeated the French, the US just stepped into their shoes. The Vietnamese saw no difference; the Americans had become the new colonialists. And while many Americans deluded themselves into thinking that we were fighting for freedom and democracy in Vietnam, it was the Vietnamese who had it right. We were really just fighting to prolong colonialism.

It was not just right-wing ideologies that were twisted by the Cold War; the ideologies of the Left also underwent a transformation, and in many ways, it was not a healthy one. Vietnam became a trigger for the belief that America could play no positive role in the world. All American military action, regardless of the purpose, came to be viewed as synonymous with aggression. The Left became champions of a new isolationism. We can hear this attitude today in the opposition by some on the Left not only against the war in Iraq, but against the war in Afghanistan as well. These attitudes on the Left carried over to economic policy, as a crude populism drifted towards economic nationalism. Free trade - the cornerstone of FDR's liberal economic world order - emerged as the bete noire of the Left. The Left became the opponent of globalization, and global economic development itself came to be viewed by many on the Left as nothing more than an excuse for profiteering by American corporations. The Right castigated the Left as the "blame America first crowd." I hate to say it, but the attack was not without basis.

The dream of bipartisan consensus collapsed. We became two Americas, one Red and one Blue. Partisanship became a blood sport. New media - talk radio, cable news, blogs - gave rise to a partisan atmosphere in which the notion of common ground became unthinkable.

That is, until November 4, 2008, and it became thinkable again. Those white folks I was keeping an eye on at the polling place in Scranton had voted overwhelmingly to elect a President named Barack Hussein Obama, whose mother was a white agnostic and whose father was a Muslim from Kenya. So too had a majority of the voters in Florida, and Virginia, and Indiana, and North Carolina - North Carolina for goodness sake! So too did every member of my family. Suddenly it became possible to believe in President Obama's vision of a country that was more than just a collection of warring Red States and Blue States, but instead, the United States of America.

President Obama has enormous substantive challenges ahead of him. We are in the deepest recession since the 1930s. Unemployment just went way up. Serious health care reform is no longer optional. We are in two wars. Al Qaeda is still out there.

But I believe that President Obama's greatest challenge transcends any substantive issue. He must rediscover FDR's vision for America and its role in the world and make it a reality. And we have to help him. We need to reclaim liberal patriotism.

It's not going to be easy. President Obama is coming under attack from both the Right and the Left. The attacks from the Right are to be expected, but the level of their viciousness almost defies belief. The attacks from some on the Left are almost as bad. Extreme partisanship has not only become a bad habit, it has become an industry. Many pundits of the Left and the Right do not want to see Americans work together, they do not want to admit of the possibility of common ground. Doing so would put them out of a job.

But there are bigger forces at work today than the insidious blather of partisan pundits. The peoples of the world stand on the brink of a new era, and it can be an era of peace, prosperity and freedom. There is no Cold War. In fact, there is no war at all among the major powers of the world and it is almost impossible to conceive of any danger of such a war arising in the foreseeable future. Economic development is on the march in China, India and Brazil. We can seriously talk about ending extreme poverty in the world. Technology has made interconnectedness and the free flow of ideas an unstoppable force. We have seen the rise of the spirit of liberty even in a country as rigid and authoritarian as Iran.

And notwithstanding everything America has done wrong in the past 50 years, much of the world still sees America as its beacon of hope. They see the America that I saw on November 4, 2008. They hear the words that inspired Mandela.

On this Fourth of July, I would like to salute my sister-in-law, a successful ob-gyn practitioner. She has gone to do volunteer work in a hospital in rural Kenya. She is one of the greatest patriots I know.