On Public Goods: Providing Education & Healthcare

[This is a rather extensive, composite response edited from a dialogue related to a friend's healthcare blog, So what do you think about that? I'm addressing points made and issues raised by another friend about public education and healthcare as public goods. We are all in the same Great Decisions discussion group in Naples, FL.]

Two Policy Questions

First, aren't there two principal policy questions we must entertain in addressing issues related to providing either public education, public healthcare or public healthcare insurance? And the answer to the first determines whether we need have anything to say about the second. The first question is whether it is a public good, whether there is a public, national interest in assuring that every child has access to a basic education and, in turn, assuring that every child and adult has access to preventive and basic healthcare. Only if the answer to either is, yes, do we need to go further and ask the second question: what is the most efficient, effective, and fair way to assure access and the value of that public service to all?

The First Question

Education

There are only three "public goods"--as I loosely define them--that appear of such national interest, benefit, and long-standing status, that they enjoy more or less an American consensus. First is the postal service, which enjoys a constitutional mandate to be overseen by the government (at least with respect to letter carrying)--but for which a case can be made that modern day letter carrying and package delivery might more efficiently serve the public by being "privatized." But, the constitutional mandate doubtless rests on national security grounds, and the status quo seems assured. The second is our standing and reserve military--and, I might add, it's full-service healthcare delivery system. Both appear to function quite well, and no one I am aware of is suggesting privatizing either--for national security reasons, no doubt, although both are also internationally best of class. (Services such as police and fire protection might also be included in a similar category.)  And the third is public education. 

It is my perception that public education is accepted by most all Americans today as a public good, broadly defined, a developmental  necessity that should be provided to all. That is, the public provision of k-12 education is too much in the national interest to leave to the uneven and too often denying allocations and administration of the marketplace. But yes, private education is also important; it provides not only an alternative for those who can afford it, but also a continuing showcase for the best practices that a fee-based market can provide, practices that could sometimes be usefully adopted by public education. But again, it is not a model that reliably delivers effective, affordable, and relatively equal education to all. And it is always expensive, most often more expensive per student than public education--at least among the better of them. (It was my personal pleasure to spend nine years on the board of a very good--and very expensive--private school, six as treasurer, three as president.)

Much has been said and written across the American centuries about the importance and power of public education, and its necessity to assure access and fair administration of basic education to all. It extends back to early colonial times with Boston Latin School being the first public school established in 1635, with girls first attending school in Boston in 1767, and the first public high school established in Boston in 1821. But education, on the whole, remained more private and unorganized until the 1840s, and the public school systems did not dominate until about 1900. By 1918, all states required all children to attend elementary school, and soon after high school attendance was required, at least until age 16 in most cases. By 1935, 40% of students were earning a high school diploma; by 1940, 50% of all young adults had earned one. Soon after the end of WWII, American public education had largely taken on the form and approach that we know today.

For most of the last century, American public education has been a model for the world, and those schools served the American public without issue or complaint. Well, there were some policy issues of course, significant issues, and principal among them were the inequities for the poorer inner-city and rural school districts, and minority community schools--including for far too long, segregated schools. (And most private schools, then or now, have done little to help advance solutions to those problems.) And yes, inequities in education in poorer communities remain a challenge today. Still, the performance of public schools in most middle class and up-scale communities has been well and supportively received--and in the main, still is today. 

But to the extent it has achieved anything close to its purposes--and even if other countries may now do it better--public education still provides the foundation for a better informed citizenry better able to contribute to civic affairs. But just as important is the basic development of creative and productive leaders and workers in government, commerce and the professions. All of this enriches and strengthens government and the economy, to the benefit of the individual and the nation. It has often been observed that after our representative democracy and creative market economy, public education is the strongest contributing factor to America's vibrant society and economic success. But I'm sure I am preaching to the choir on this point.

Further, it might be relevant to consider that every advanced country and most others today provide public k-12 education. And whether they do it better or worse than we, it's value and necessity is universally recognized.

Why not higher education, too, you ask? And you're right to ask. The most logical and pressing open question regarding public education may be whether there isn't a need to expand its scope as a public good to include higher education--both academic and vocational. An advancing world and economy now demand more education for today's elevated job requirements, and to command middle-class or higher salaries. The issue has taken on more importance in recent decades as the utility and value of a high school diploma has declined.

But there is a related issue, an equally pressing need: the need for  higher education to be reformed and restructured to overcome its muddled mission and overwhelming and increasing cost. More and more often, it fails to provides a justifiable return on cost to students, their families, states and the nation. It has become beyond the ability of most families to prudently finance, and indefensible levels of higher education debt threaten the financial future of students and families alike. There are well understood reasons why (at least by researchers in the area), reasons that can and must be addressed.

But reforming and restructuring higher education--and especially research universities--will likely prove just as difficult as reforming and restructuring healthcare. It would seem to me that there should be greater emphasis on separating the teaching and research functions so each stands on its own in terms of justifying its focus, scope and methods, managing its cost and revenue needs, and serving its different publics. The training of Ph.D researchers would likely be found in the research institutions, while BA and MA degree teaching would be found in the teaching institutions. Graduates with MA degrees should be qualified to teach in those BA and MA granting teaching institutions.

Then there is the real, market-driven competition for the best of everything non-academic: athletic teams and facilities, far more upscale college dorms, dining and recreational areas. All this drives up cost and tuitions. Fair consideration of alternative models or approaches is a necessity, but only cost and tuition levels that no longer allow schools to fill their classes will cause them to take alternatives seriously.

The less ambitious nature of the simplest four-year state colleges that focus principally on teaching has much to recommend it. So do the community colleges and their more utilitarian approach to vocational curricula and two-year academic preparatory programs--although, they too might be better served by separating those missions and functions for more effective focus and management. They also need to think more about converting their no-frills teaching competency to four-year undergraduate programs in more cases. The demand for them is likely to quicken as the financial breaking point is recognized by more middle-class families.

When more middle-class kids and families fully appreciate that they can spend their first two academic years at a community college and the last two years at a competent state college--or all four at the less expensive community college--and that it likely won't make much difference in their long-term career success, won't there will be a significant migration in that direction? And won't that place enormous pressure on private and public research universities to think about restructuring?

You see, even if cost alone were not enough to instigate this change in demand, recent research might tip the balance. The research I'm talking about is a longitudinal study that finds that kids with the same SAT scores and high school performance who go to the most prominent schools they can get into--including the Ivies and other elite schools--have, on average, no more long-term career and financial success than those who attend less prestigious, less expensive schools, including state colleges. That is, a similar level of ability and industy, combined with a competent college education--whether at an Ivy or a basic public college--usually yields a similar level of success.

In addition to popular lore, don't we already understand that instinctively, empirically? Of course, there's always the cache and appeal that attaches to brand-name schools--and they may make a difference in opening those first doors. But are they worth subverting one's financial future when, in the end, ability and industry will more likely open the doors to your long-term future? For most middle-class and less well-off families and students, it is not.

Like k-12 education, the case for including higher education as a public good has now become more compelling. It is where the demands of advancing technology, commerce, and a more competitive world economy have taken us. Which, in turn, makes the case for reforming the delivery system for higher education all the more compelling.

Healthcare

And it is because of the universal recognition of public k-12 education as a public good that I consider it a useful analogy in addressing the mature case, the compelling national need, for universal access to preventative and basic healthcare services. It too must be recognized as a comparable public good.

Against that storied educational history and revered contribution to America's strength and identity, what can we say about the case for public access to preventative and basic healthcare? Well, we can begin by pointing out that as societies advance, as they reach higher in all aspects of the quality and strength of social and economic life, more is demanded from each person, social institutions, and government leadership--greater capability is required for  greater contribution. We can observe that it has been long understood, and made clearer with time, that untreated illness, disease, and physical dysfunction, create a costly, retarding effect on the advancement of American culture and the growth of our economy. For decades, insightful employers have provided fitness centers or memberships, and done what they could afford to provide health insurance to cover basic healthcare, at least. They understand the benefit and payback in productivity terms--even if they are poorly situated, and often unable, to properly and fairly manage it.

But more insidious is the effect on children of untreated, often chronic illness or disease, most often poor children. For them, it is not just about the temporary loss of productive time; rather, like poor nutrition, it often becomes a life-long limitation on readiness and ability to learn, on the future level of employment or on employment at all, about realizing human and productive capability. And the cost to society and the economy is great. The research and its implications have been piling up for decades. It seems to me, at least looking through my eyes, assuming my values and understandings, it is not the case for universal access to healthcare that is weak, it is the leadership of our national politicians, and the related understandings of some political constituencies.

But it is also important to reemphasize what I have stated before about a cost-justified definition of "preventative and basic healthcare," my term of preference in referring to public healthcare or healthcare insurance--and why that's important. Politicians are loath to address the true complexities, needed private and government discipline, and necessary cost reduction in the system. And yes, that includes "rationing," intelligent cost-benefit trade-offs, by some well-informed, responsible, public policy standards. After all, we are already rationing health care services through the haphazard mechanics by which the system now provides or denies service to various classes of patients. And it is class-and-income based.

Too often that means denying preventative and basic care to poorer children and adults, which is inexpensive and strengthening of our national health and productivity, while at the same time accepting unlimited costs--35-40% of all healthcare costs--to keep aged or terminal patients alive for another week, or month or so, in the last year of life. We routinely over-test and over-prescribe, and unnecessarily use the most expensive alternatives in diagnosing and treating many illnesses. Defaulting to this unaccountable system that makes those decisions is a most irrational and indefensible way to set public policy on providing healthcare. And make no mistake about it, it is a default policy--and one that does not serve our people or our country intelligently, cost-effectively, or well.

We need an approach that sets appropriate, cost-defensible priorities if we are to have an effective, sustainable healthcare delivery system. And, for those who want more, who can afford it, there will always be a market for supplemental healthcare plans, "Cadillac plans" that offer coverage including the most expensive alternatives, or continuing care and life support to the terminally ill.

The healthcare needs of the American public have long cried out to be treated as a national priority. Now the case is clear: the national interest demands that healthcare be treated as a public good, a service which all Americans, whether rich or poor, should have access to at a cost reasonable and appropriate to their means. I wish I could just declare that it should be every American's right, a matter of their quality of life, pursuit of happiness, and fulfillment of their potential, and that would make it so. But in the end, I also know it has to be paid for. In the end, it also has to be justified to some reasonable extent in economic and productivity terms as well. And it can be if our leaders can marshal the strength to lead.

And here, I must also point out that, notwithstanding the cost and challenges, all advanced countries today provide universal access to healthcare, except America. Among those most advanced who provide healthcare through a national health service, the cost per capita is approximately half that of the U.S. And in most of those places, it is viewed as a right of all. We are the outlier. Now we may be right and the world wrong, but the answers I find provide little to support for that conclusion.

The Second Question

Healthcare

At this point, I'd ask that you indulge my analysis and conclusions on the step-one question--whether you are persuaded by them or not--so that we can move to the step-two question: what is the most efficient, effective, and fair way to assure access and the received value of that public service by all?  And it may be that many of the step-one concerns or issues can be be resolved in more intelligently designed and implemented structures animated by better-aligned incentives.

First, I have no ideological predisposition to any particular way that either public education or public healthcare/insurance might be delivered. It's whatever approach touches all the bases most efficiently and effectively. I'm an advocate of market answers in the production or provision of most goods and services. But, I do not believe that markets and market providers can be relied upon to touch those bases of fair and equitable service provided at fees reasonable to all consumers' means. It's not the way markets work.

Perhaps there is a better way to  think about the role of government and role of markets that incorporates the necessary accountabilities, best features, and most efficient contribution of each. Let's explore the possibilities of such a model and role definitions. The function of the market is to drive the best quality, lowest price product or service to meet (or create) specific needs of customers able to pay. The role of government--in this context--is to protect its citizens and taxpayers, and provide them or pay for needed services judged a national priority--and do so on an equitable basis.

If we were to visit that approach on a solution to our problem, it might look something like the healthcare legislation we now have. But as I have written before, the unfortunate, politically bastardized result takes us only half way there.

That is, the only way we get there is for government to exercise fully and more intelligently its legislative, regulatory and financing role, restructuring the requirements and incentives of market product and service providers, eliminating the counterproductive and unnecessary role of private insurers (who do not act in the patients interest or the national interest, where the government arguably does), assuring cost accountability, and restoring the patient to a meaningful role as consumer and judge of services rendered, even if he is not--and cannot be--a meaningful party in setting prices.

I believe that taking this legislative and regulatory process to its logical conclusion can provide a workable healthcare delivery system--perhaps even an efficient and effective system--one that incorporates as much as is practicable, significant market elements or features. But again, what is most important is the presence of an intelligently designed system. It must have properly defined roles, responsibilities, and accountabilities--and the most effective and appropriate incentives to assure a competent and efficiently provided service. All things that do not exist now.

Education

Education today is also complicated. It is being delivered in different settings to different populations with their own unique characteristics and needs. It is one type of challenge to deliver effective education to students in an upscale community with relatively stable families, including parents who are college educated and successful. These are parents who most often encourage and prepare their children to attend college--and more, create in their children the expectation and confidence that they will attend and graduate from college. Those are what the research tells us are the most influential factors in the educational success of most students.

But it is a very different challenge, and demands a very different approach, in delivering effective education to the directionless child from a poor, dysfunctional family--often a single-parent, inner-city or rural family where the parent is struggling to survive with children. Most often, the parent(s) fail to adequately encourage their children's education, at least with the needed confidence and credibility . Too often, the result is a failed or underperforming student. If you pair that with poor nutrition and inadequate healthcare, the probabilities of failure are greater still. Only an extraordinary parent and child, an influential peer, or the credible intervention of a teacher, coach, faith leader, or other role model willing to make an exceptional personal investment can provide the special support necessary to sufficiently lift such a child's confidence and hope. (The dissertation I had to abandon because of chronic illness was to have been on this topic.)

And then there are the issues you may be thinking about: the poorer relative performance of American students on international standardized tests of learning. For at least two decades a debate has been going on, a debate that has moved us toward more rote learning of facts and a curriculum oriented to preparing students to perform better on those tests. So far it does not seem to have helped much. Attending it has been a debate about appropriate incentives for teachers and school systems to help bring us again to the top of the testing ranks. But various experiments with that have not been notable for their clear success, either.

More, during this same time when more emphasis has been placed on factual knowledge--often to the exclusion of discussion and problem solving time--student scores on tests of creativity (the Torrance creativity index) have also been steadily declining. Interestingly, the Asian tigers, and particularly China, have observed that while America is moving away from her older pedagogical model, they are moving toward it. Creativity is now first on the minds of Asia and Europe. America is now more concerned with scores. Surely, the better answer is a balanced approached to both, a curriculum that sets the exposure to and teaching of factual knowledge within the context of discussion and problem solving. (I recently posted a piece to my blog site on this subject, "Flagging Student Creativity.")

It has been observed that public education too often serves first the teachers and administrators. Teachers unions have long been allowed to insinuate themselves too deeply into educational policy making, and too often frustrate reform, changes that would strengthen curriculum or the educational experience, that would allow the dismissal of underperforming teachers, and would set salaries and benefits by market driven standards. It is an excellent example of how dysfunctional and counterproductive roles and incentives can become. And if there is a major difference that I would identify between public and private education, it is that. I hope we can agree that American public education cannot address and effect needed reform until the influence of unions on education policy is limited to an advisory role--and teacher hiring, retention and advancement is based on performance evaluation.

What about something like voucher programs, you ask? Good question. Is there any practical opportunity to employ them in public education? Perhaps, but we know the notion of a voucher program makes many public education advocates just too uncomfortable. Yet, shouldnt we explore further that possibility? But first, we need to get back to our model of government and market roles.

In the case of education, insurance is not the role of government, direct provision of service is. But in looking at the possibilities and promise of a voucher program, we are asking whether government could and should take on a variation of the role of insurer, guarantor--or payor, by whatever name--for the cost of private education in the marketplace. That is, they would offer to pay a private school the average cost of a public school student if the private school would accept the student on those financial terms. Oh, but the school should also have to meet the basic curriculum requirements of the public school department--or something comparable to it--and student performance by some comparable measure would have to equal or exceed the public school measures. Yes, in this way, the private school becomes an extension of the public school system, a next step removed from charter schools, but nonetheless generally accountable to public school policy setting, curriculum development, and performance expectations.

Of course, there are few strong private schools that would agree to all that, likely very few. And the ones that would, would too often be new or failing, those with financial, leadership or accreditation issues. Again, proven performance against public school requirement and measures would have to be non-negotiable. That is what it would take, I think, for public authorities to be comfortable in their responsibilities for the education of public school students, and the use of public tax resources to fund it. But attempts have beeen made to experiment with vouchers.

As I remember, there were several earnest attempts at test programs starting in the 1990s in places like Milwaukee, NYC, Washington, DC, and Dayton, Ohio. And there may have been others since 2003 when I stopped followed this topic closely. But the results were uneven, sometimes inconsistent. There were some modest successes, especially with inner city black students. And there are other studies that appear to show increased success of inner city black students enrolled in urban parochial schools. Unfortunately, none of those studies were controlled enough to confidently eliminate a number of potential influences on the results, both positive and negative.

And then there are the more practical problems, the same problems that would face an attempt to move en masse toward a patchwork quilt of charter schools. There are the issues of public responsibility and accountability to assure adherence to basic curricular coverage, performance measurement processes, and student performance standards in a range of different types of schools. But that is not an insuperable problem; if school system authorities really wanted to make it happen, they would. 

But there are more challenging problems, perhaps insuperable problems. To the extent that enough private schools--or charter schools--agreed to meet all criteria required of them and were approved, they would create excess capacity and inefficient economies of scale in the public infrastructure.  The process of unwinding, reallocating or selling existing infrastructure, and unwinding or restructuring the management and teacher staffing of existing public school systems would likely prove very expensive, and very disruptive, too.

I'm sure you appreciate what an ugly, dysfunctional, near impossible political and professional process that would likely be. And the political compromise required for any kind of agreement would likely produce an unsatisfactory result in its own right. A more measured and stable process, by necessity an incremental process, would take many years--if the agreement of the required parties could ever be negotiated. But just as bad might be the more likely, part-way case where the system must still support much the same infrastructure and retain near the same level of teaching and other staff, but without the same revenues to support them. I am much less encouraged about the role of voucher programs than I once was.

Then how about charter schools? Charter schools have been a great idea, although results have sometimes been uneven. In some states that adopted a wild-west, open marketplace spare on regulation, accountability and experience--Arizona comes to mind--the results ranged from encouraging to distressing. There were good stories and very bad stories. (Although I haven't kept up with them the last few years.) Other states have gone more slowly, and the results have been more consistently good. With their relative success came the approval for a few more, then more still. In most states, charters still do not appear a prominent factor in public education, but most of the ones that exist are succeeding, and doing innovative things with teaching and curriculum. And that means their students are most often succeeding.

And the ones that are serving best, and bringing the most attention to themselves at the same time, are in urban settings. Given that, and the appearance of satisfaction with most suburban schools, I see charter schools as more an adjunct, experimental arm of public education, most needed and most helpful where special challenges or system failures face a school system--an educational "skunk works," so to speak.

It seems to me the prescription for public education remains to "simply" effect the necessary changes of roles, responsibilities and accountabilities of teachers and their unions, parents and administrators. The changes should provide appropriate incentives to assure that the best, most balanced curriculum is employed and constantly reassessed, the most effective teaching is being developed and delivered, and the best educational results are realized as determined by an appropriate and fair range of performance measures for teachers and students alike. And teacher hiring, retention, advancement determinations must be made on those performance measures. But there is nothing simple about that prescription. Efforts to that end have been made by many for a long time.

Still, I remain optimistic that our public school systems can retain the best of what they do, take the most effective practices developed in charter schools, and bring better, more efficient education and student performance to our most challenging urban and rural school systems--and to the suburbs, too. It can be done. But as we've already seen, it will take a lot of public dissatisfaction, worsening budget challenges, and a lot of honest self-examination and willingness to change by our strongest political leaders, school system administrators, and teachers. At least that's the way it appears to me.

Wild Geese

 By Mary Oliver

from Dreamwork (1986)

a favorite of mine, and so many others:

Wild Geese

You do not have to be good.

You do not have to walk on your knees

For a hundred miles through the desert, repenting.
You only have to let the soft animal of your body

love what it loves.

Tell me about despair, yours, and I will tell you mine.

Meanwhile the world goes on.

Meanwhile the sun and the clear pebbles of the rain

are moving across the landscapes,

over the prairies and the deep trees,

the mountains and rivers.
Meanwhile the wild geese, high in the clean blue air,

are heading home again.

Whoever you are, no matter how lonely,

the world offers itself to your imagination,

calls to you like the wild geese, harsh and exciting--

over and over announcing your place

in the family of things.

Healthcare & Cost Reduction, Market & Public Realities

To a former moderate Republican, the redefined and redirected Republicans of the last decade bear little resemblance to who and what they once were--and their actions even less so. What happened to the party of fiscal and budgetary responsibility? What happened to their instincts for compromise--and what little forward looking and adaptive capacity they once may have had?

The subject is health care reform, its importance to our nation and our economy, the cost-reduction and cost management commitment healthcare reform demands, and the lack of adequate Republican and Democratic cost accountability in cobbling together and passing the "Patient Protection and Affordable Care Act" (PPACA). In the end, it didn't do near enough to assure healthcare will be more affordable in the future. But it did what it could and still assure passage--and that was to establish the new Independent Payment Advisory Board (IPAD). But for reasons that escape reason and responsibility, the Republicans now want to rescind the provision that established it.

In her healthcare blog, What do you think about that?, Sandy Parker recently addressed "The Health Care Bureaucrats Elimination Act," the latest puerile tactic and misdirection play by the Republican leadership. An excerpt from her blog post: 

One of the benefits I hope you will gain from reading my blog is information you can and will use to dispel some of the falsehoods (dare I say outright lies?) you'll be hearing from friends and colleagues in the months leading up to the 2010 and 2012 elections. The "Health Care Bureaucrats Elimination Act" is one of those things.  I learned of it from an editorial in today's New York Times:

Republicans claim to be deeply worried about the deficit — their favorite political target, followed closely by President Obama's relentlessly demonized health care reform. So why are they so determined to overturn one of the central cost-control mechanisms of the new reform law?

Republicans in both the Senate and the House have introduced bills that would eliminate the new Independent Payment Advisory Board, which is supposed to come up with ways to rein in excessive Medicare spending — and stiffen Congress's spine.

Starting in 2014, whenever Medicare's projected spending exceeds a target growth rate, the board of 15 members (drawn from a range of backgrounds, appointed by the president and confirmed by the Senate) will have to recommend reductions in payments to doctors and health care providers to bring spending back to target levels. These recommendations would become law unless Congress — not known for its political courage in such circumstances — passed an alternative proposal that would achieve comparable savings.

None of this poses any real threat to Medicare beneficiaries. The law prohibits the board from making proposals that would ration care, increase taxes, change Medicare benefits or eligibility, increase premiums or cost-sharing, or reduce low-income subsidies for drug coverage. It cannot call for a reduction in payments to hospitals before 2020.

If anything, we fear that the board's power will be too limited. But its power to curb payments to other providers is projected to save $15.5 billion to $24 billion between 2015 and 2019.

That has not stopped Senator John Cornyn of Texas from trying to kill off the board. In July, he introduced the ever so cutely named "Health Care Bureaucrats Elimination Act." It currently has 11 co-sponsors, and a similar version, introduced earlier in the House by the Republican Phil Roe of Tennessee, has 54 co-sponsors.

Neither bill will go anywhere so long as the Democrats run Congress, but expect to hear a lot of hype about bureaucrats hijacking health care — and nothing about the needed savings — in this fall's campaign.

"Come Again? ,"  New York Times, Editorial (8.22.10)

What the Republicans also fail to acknowledge--never mind address--is that our patchwork-quilt of a healthcare system in no way resembles an efficient, accountable free-market process where healthcare consumers--that is, patients, not insurance companies or corporations--play a material, market role in levels of services provided and mechanisms of pricing. As you have already pointed out in an earlier post, it is unresponsive and unaccountable to patients, who usually have no idea what the actual cost of alternative services are--and quite often, neither do doctors. That is laissez faire turned on its head in the most bizarre fashion. It bears only the most distorted resemblance to a well-functioning market that is responsive to customers and efficiently drives services and sets prices.

It is a system whereby the hospitals, docs, and insurance companies blithely and happily shrug their shoulders as they allow their system to drive health care cost upward--to all their benefit, apparently. More and more, corporate employers just want out of the out-of-control system. Their mission and orientation is poorly matched to managing a public service. In the end, it is just another cost corporations manage by reducing, and most of that reduction comes in fewer services and more cost borne by employees. It's just the way it works. Small businesses just aren't interested at all. It's a huge burden to them. And taxpayer-patients just want competent healthcare services available at prices they can afford. And the number of patients without anything resembling that is large and growing--and in this time of the Great Recession, it's rate of growth is increasing significantly.

Politicians are loath to address the true complexities, needed private and government discipline, and necessary cost reduction in the system. And yes, that includes "rationing," intelligent cost-benefit trade-offs, by some well-informed, responsible, public policy standards. After all, we are already rationing health care services through the haphazard mechanics by which the system now provides or denies service to various classes of patients. And it is class-and-income based. 

Too often that means denying preventative and basic care to poorer children and adults, which is inexpensive and strengthening of our national health and productivity, while at the same time accepting unlimited costs--35-40% of all healthcare costs--to keep aged or terminal patients alive for another week, or month or so, in the last year of life. We routinely over-test and over-prescribe, and unnecessarily use the most expensive alternatives in diagnosing and treating many illnesses. Defaulting to this unaccountable system that makes those decisions is a most irrational and indefensible way to set public policy on providing healthcare. And make no mistake, it is a default policy--and one that does not serve our people or our country intelligently, cost-effectively, or well.

But then, even if we could achieve an efficient market-based healthcare system, one that more intelligently drives provision of services, quality and competitive pricing, it still would not do, would it? And the reason is that, for all its power, creativity and efficiency, markets do not provide equal, fair, or consistent service to all. By its very nature and mechanics, it provides more and better services, or less and worse services, across a spectrum of customers--or patients--based on their ability to pay. Markets just do not operate efficiently or fairly to provide public services of some definition on an equal basis to all. Because it is a public good, a public need, and arguably should be a public right--just like k-12 education, and for the same reasons--healthcare services must be overseen, regulated, and administered as a matter of responsible, accountable public policy. And to some material extent they must also be delivered as part of a public program and process.

Of course, wherever possible, market mechanisms and accountability must be embraced in the production and provision of healthcare goods and services. But they must also be available to all at a cost they can afford, which requires means testing--and it requires that the government is the payor for those who cannot afford all or even some of the cost.

Some combination of public and private insurance may be possible, although the self-interested machinations of private insurers (sometimes in league with corporate clients) have been the culprits behind many inequities and outrageous policies that have frustrated fair administration of today's "market-based" heathcare. For in the end, isn't it clear that it has been the private and public insurers, and the corporate employers, who have been the healthcare systems real customers, not the patients? In the end, only a public single-payor mechanism will likely serve us well. And remember, the customer--the patient--has to play a meaningful role in quality and satisfaction determinations, and that patient must also be aware of the cost and relative cost of alternative healthcare services provided. Responsibility and accountability must be the watchwords throughout.

A national health service? Well, we have a full-blown, fully-functional national heath service for the military and veterans, especially veterans with service-related disabilities. By all accounts, it works quite well. In my time of service, it worked well enough for me. But we are--politically speaking--at least a decade, perhaps a generation, away from taking seriously the potential superiority of such a system of delivering public healthcare. This is so even though advanced countries with national health services enjoy cost per capita of approximately half that of the U.S. And, it would also require a dismantling, or at least an enormous and completely disruptive restructuring, of our current healthcare delivery process, a daunting prospect. Any change of that magnitude would likely have to be incremental, and would take years, likely a decade or more. Of course, even moving to a single-payor (government insurer/payor) system would require significant restructuring and change in both private and government insurance structures and capability, requiring a years-long transition period.

But we've taken a step in that direction, an important step, actually--but mostly on the issues of access and equity, halting unfair practices of private insurers, etc. Very little has been done to materially reduce and control cost. But, as noted above, neither the Republicans (inexplicably) or some of the Democrats wanted to go there. We can only hope that there will be next steps, and those next steps will more effectively address cost reduction and control--and if it is still as apparent as it is today that a single payor system will serve us better, perhaps another step in that direction, too. But in the meantime, the least we can hope for is the reasonable success of the IPAD--and first, a full and fair opportunity for it to function as intended.

It took a long-term lack of public and market accountability for this godawful healthcare delivery system to evolve. It will take a long-term, incremental evaluation and change process to get it anywhere near as efficient, fair and accessible as the American people need, as productive as American business demands, and as wisely approached as American public policy should now dictate.

The Right: Agree with Us or You're Un-American; The Economist: Phooey to the Right!

So, it has come to this, the next desperate, misguided--and I might add, "un-American"--gambit of the ideological Right. In a nutshell--and quite explicitly--many spokesmen of the ideological Right are saying that if you don't agree with their definition of America and limited American government, then you are un-American. And that probably includes most Americans, at least if we really understand the full implications of what these self-interested, lost thinkers truly suggest.

They are trying to bully us all into a definition of government that ill-serves most Americans, one with much smaller government structures, functions and capabilities, and many fewer public services--the less and fewer the better. And the only people that benefit from this are people who can afford to pay for the best of private healthcare, who care little for environmental reform or services to others that may increase their taxes, and are indifferent to financial reform because their net worth is substantial enough to ride it all out. Everyone else--those who truly need the help--get less and suffer more. And the strength and social fabric of our nation and economy suffers with them. But hey, the well-off have theirs. I know. I am fortunate enough to be among them.

To express agreement with Obama's initiatives to provide access to healthcare to those who are out of work or cannot afford it, to reform the financial system so we are unlikely to have another financial disaster like the one we are still trying to lift ourselves out of, to try to protect our environment in the face of global warming, are apparently all things the ideological Right feel are un-American and require an un-American-sized government to provide. This is blinkered, irresponsible thinking, at the very least. And so very anachronistic, so 19th century.

Very recently, I was made aware of how clearly and sharply the new battle lines had been drawn when healthcare blogger (What do you think about that?) and friend, Sandy Parker, sent me a recent piece from the influencial blog, Politico, provocatively titled, "The New Battle : What it means to be American." Then, the most recent edition of The Economist on-line hit my in-box, and addressed the Politico article. And they say it better and with more credibility than I can. From The Economist:

LAST Friday Jonathan Martin and Ben Smith published a piece in Politico entitled "The New Battle: What it means to be American." The gist of the piece is that conservatives and the Republican Party are moving away from culture-war issues and towards a struggle over the appropriate size and role of government. "Much of the right—including the noisy and influential tea party movement—sees greater and more immediate danger from this administration and Congress on issues related to the role of government and the very meaning of America than from the old 'social issues,'" they write. 

...Let's take a look at the elision in that sentence: the part where we move from "the role of government" to "the very meaning of America". What is the relationship of "the role of government" to "the very meaning of America"? There are certainly some functions that government assumes in other countries which are clearly un-American. For example, in some countries, the government enforces an official religion. In other countries, the government imprisons people and tortures them without trial. (Ahem. Let's not get into that for now.) But the left is at least as adamantly opposed to government playing these sorts of roles as anyone on the right is. So how does today's right see "the role of government" as a dividing line between the right and left, in a sense that affects "the very meaning of America"? Here's former Bush administration official Peter Wehner:

"What we're having here are debates about first principles," Wehner said. "A lot of people think [Obama is] trying to transform the country in a liberal direction in the way that Ronald Reagan did in a conservative direction. This is not the normal push and pull of politics. It gets down to the purpose and meaning of America."

In the view of National Review editor Rich Lowry, that sense on the right of a fundamental shift has helped turn the role of government into a cultural issue, filling some of the emotional space formerly occupied by the traditional hot-button issues.

Questions about the role of government "have a cultural charge because people feel the definition of the country is changing," Lowry said.

Just as Christian conservatism in the 1970s and '80s grew as part of a backlash against what were seen as the cultural excesses of the '60s, the new right of today amounts to a rebellion against the perceived threat of this era—a slippage toward European-style social democracy.

Oh, okay. The phrase "European-style social democracy" isn't actually entirely clear; the United States is, in every meaningful sense, a European-style social democracy, albeit one with relatively low taxes, relatively parsimonious government entitlements, and relatively spectacular national parks. But you get the drift. The right, in Messrs Martin and Smith's telling, is arguing that the "purpose and meaning of America" are not compatible with the economic elements of Barack Obama's legislative agenda. That agenda, last time I looked, chiefly comprised universal health insurance, regulation of the financial sector, a carbon tax or carbon emissions limits, and an approach to shrinking future budget deficits that will fall more heavily on the rich and involve fewer cuts to existing social services and entitlements. Mr Wehner and Mr Lowry, like many tea-party demonstrators, think that this economic agenda is un-American.

...Let's put it this way: I support the Affordable Care Act, known to the right as ObamaCare. I do not react well to being told that my position on this issue does not comport with "the purpose and meaning of America". I see not a shred of evidence for such a claim. In fact, I believe that my support for universal health insurance, like my support for universal education, is rooted in the greatest traditions of American history and political thought. No doubt Messrs Wehner and Lowry feel the same about their positions on universal health insurance. The difference is that I'm not going to accuse them of betraying "the purpose and meaning of America." I am not trying to turn a dispute over what government should do to improve America's social and economic fairness and well-being into a shouting match over who is or isn't a real American.

But that's what Messrs Martin and Smith say the right is trying to do. If so, then phooey to the right. That's not less acrimonious than the culture wars. It's worse. Here's a culture-war argument: you say America is a Christian nation; I say America is a nation where Muslims and anybody else has the right to worship two blocks from ground zero. Here's another culture-war argument: you say America's freedom is under attack and we can't afford to give terrorists constitutional protections against torture; I say those constitutional protections against torture are exactly the freedom we're trying to defend. Both of these are real arguments about the meaning of America, with roots in the country's founding documents and originating political events. If you want to accuse me of being un-American in an argument like that, I'll argue you're wrong, but I can see why the accusation is germane, and I may call you un-American in your turn. But to call someone un-American because of their position on relative levels of taxation or the government's role in regulating and guaranteeing health insurance is an attempt to enlist nativist fear and vindictive nationalism in the service of one's own economic agenda. It's an outrageous tactic, and it ought to be completely out of bounds.

---"Universal health Insurance is un-American?", The Economist, Democracy in America section (8.23.10)

So, it appears that spokesmen of the ideological Right have decided that the only thing left to them is to try again to bully and intimidate middle America into joining them--or be ready to be taunted as un-American. It worked to some degree during the '60s and the Vietnam War, right? If you were against the war or for social reform you were called out as un-American. It managed to keep silent a lot of the "silent majority." But it didn't work very well for very long, even then, not really. And I don't think it's going to work very well now.

That is especially true now that the Republican Party has succeeded in defining itself as only the true believers of the extreme ideological Right. Lots of folks who used to consider themselves moderate Republicans, free-market advocates who were progressive on social or cultural issues, now have found more identity and safer travel as Independents, progressive to a greater or lesser extent, or as Democrats. Regardless, they now most often vote with the Democrats out of conscience.

But fear not. For the Right will never get away with denying the reality of America's rich political, economic and cultural history. Out of desperation, they can try, but they must fail. They--and all of us--must recognize and honor America's rich veins of political, economic, and social thought that broadly inform and animate her traditions, and constitute her identity. First, of course, is representative democracy, our republic. But then, sharing the role of her strongest expressions and influences are her robust, creative, free-market economy, intelligently regulated, and her responsiveness in meeting the basic needs of her people, especially the basic social needs of the poor, the aged, the ill and unable. And if universal education is a necessity to meet the basic needs of a contributing citizenry, and the increased productivity demands of our economy, so is access to basic healthcare for all. And all should recognize our need to protect the land, air and water that sustains us.

And be assured, nowhere in our constitutional history or tradition, our political history, or our history of government, is there an American "first principle" addressing the size of government. It always has been and always will be big enough to effectively protect the freedom and meet the needs of America's people, and protect the vitality and proper functioning of its free-market economy. The cost must be fairly, progressively shared among those who have much and those who have less, but should never be an unfair burden on those who have little. And while many of the well-off may quietly believe that the size of government, the shape and function of the marketplace, the resulting nature of our taxing regimen and the amount exacted must serve them first, they are wrong.

The 20%

This excerpt from my last piece bears repeating--and cries out for understanding:

According to a recent poll, 20% of Americans still want to believe President Obama is a Muslim, when he is an active, professing Christian. (As though it should be a problem if he were.) Most of those same people apparently want to believe he is a socialist, when he is an advocate of a robust, creative and intelligently regulated free-market economy--but one that also funds the social programs that identify a modern, advanced society, those necessary to strengthen, stabilize and perpetuate it. (And they don't appear to know the difference.) But there's always the 20%.

The Economist: Obama No Socialist

Promoting education and healthcare for all, providing for the poor, and protecting the environment does not a socialist make. And neither does the bold, informed action of President Obama and his administration in providing temporary, public investment capital to General Motors, a manufacturer and employer important to our economy. Not when restructuring and recovery were quite possible, even quite likely. Not when a return to private ownership and successful market participation was the only purpose and goal of government intervention. And not when the controlling investment in GM stock was so structured that a successful turnaround by GM allows them to buy out the government investment as soon as they are able--and with a likely profit to the government and taxpayers.

Yes, I had my reservations, too, but on balance trusted Obama and the analysis of his team in those challenging times without precedent. It was trust well placed.

General Motors has made the most of the Obama administrations decision. The huge company was significantly restructured and downsized, and now has become competitive again. Their recent market performance has been strong--profitable--and promising. And now they have announced a public offering of their securities, the proceeds of which will be used to buy back the controlling interest in their stock from the government. In the process, the US government and the American people will have saved a substantial employer and contributor to American economic life. And yes, the taxpayers will likely realize a profit, too.

And now that Obama's goal for GM is about to be realized, perhaps he might receive some simple acknowledgment of his basic intentions and success? Some respect? Trust? Basic credibility? But no, not likely.

And so it falls to The Economist--the most credible spokesman for, and defender of, the high ground of a healthy free-market economy and the social programs necessary to support, strengthen and stabilize it--to render an accurate and fair assessment. From The Economist:

An apology is due to Barack Obama: his takeover of GM could have gone horribly wrong, but it has not.

AMERICANS expect much from their president, but they do not think he should run car companies. Fortunately, Barack Obama agrees. This week the American government moved closer to getting rid of its stake in General Motors (GM) when the recently ex-bankrupt firm filed to offer its shares once more to the public.

...GM was on the verge of running out of cash when Uncle Sam intervened, throwing the firm a lifeline of $50 billion in exchange for 61% of its shares...Many people thought this bail-out (and a smaller one involving Chrysler, an even sicker firm) unwise. Governments have historically been lousy stewards of industry. Lovers of free markets (including The Economist) feared that Mr Obama might use GM as a political tool: perhaps favouring the unions who donate to Democrats or forcing the firm to build smaller, greener cars than consumers want to buy. The label "Government Motors" quickly stuck, evoking images of clunky committee-built cars that burned banknotes instead of petrol—all run by what Sarah Palin might call the socialist-in-chief.

Yet the doomsayers were wrong...Mr Obama has been tough from the start. GM had to promise to slim down dramatically—cutting jobs, shuttering factories and shedding brands—to win its lifeline. The firm was forced to declare bankruptcy. Shareholders were wiped out. Top managers were swept aside. Unions did win some special favours...but by and large Mr Obama has not used his stakes in GM and Chrysler for political ends. On the contrary, his goal has been to restore both firms to health and then get out as quickly as possible. GM is now profitable again and Chrysler, managed by Fiat, is making progress. Taxpayers might even turn a profit when GM is sold.

So was the auto bail-out a success?...Given the panic that gripped private purse-strings last year, it is more likely that GM would have been liquidated, sending a cascade of destruction through the supply chain on which its rivals, too, depended. As for moral hazard, the expectation of future bail-outs may prompt managers and unions in other industries to behave rashly. But all the stakeholders suffered during GM's bankruptcy, so this effect may be small.

Socialists don't privatise

That does not mean, however, that bail-outs are always or often justified. Straightforward bankruptcy is usually the most efficient way to allow floundering firms to restructure or fail. The state should step in only when a firm's collapse poses a systemic risk. Propping up the financial system in 2008 clearly qualified. Saving GM was a harder call, but, with the benefit of hindsight, the right one. The lesson for governments is that for a bail-out to work, it must be brutal and temporary. The lesson for American voters is that their president, for all his flaws, has no desire to own the commanding heights of industry. A gambler, yes. An interventionist, yes. A socialist, no.

---"General Motors: Government Motors No More," The Economist, Leaders section (8.19.10)

Yet, the agents of the ideological Right, the populist demogogues and bigots, too, continue to perpetuate lies and ill wishes toward President Obama. And too many uninformed or ill-informed Americans embrace them so readily and desperately.

According to a recent poll, 20% of Americans still believe (or want to believe) President Obama is a Muslim, when he is an active, professing Christian. (As though that should make a difference.) Many of those same people, and others, apparently believe (or want to believe) he is a socialist, even as most of them apparently lack any useful understanding of what the term actually means. That, or they find it convenient to ignore Obama's advocacy of a robust, creative and intelligently regulated free-market economy, a healthy economy that also funds the social programs that identify a modern, advanced society, and are necessary to support, stabilize and perpetuate it.

End Game: Pakistan & Its Taliban Strategy

First, some quotes from Newsweek and Time:

"At least we have something in common with America," the [Taliban] logistics officer says. "The Pakistanis are playing a double game with us, too."

Pakistan's ongoing support of the Afghan Taliban is anything but news to insurgents who have spoken to NEWSWEEK. Requesting anonymity for security reasons, many of them readily admit their utter dependence on the country's [Pakistan's] Directorate for Inter-Services Intelligence (ISI) not only for sanctuary and safe passage but also, some say, for much of their financial support. The logistics officer, speaking at his mud-brick compound near the border, offers an unverifiable estimate that Pakistan provides roughly 80 percent of the insurgents' funding, based on his conversations with other senior Taliban. He says the insurgents could barely cover their expenses in Kandahar province alone if not for the ISI. Not that he views them as friends. "They feed us with one hand and arrest and kill us with the other," he says.

---"With Friends Like These...," by Ron Moreau, with John Barry, Newsweek (7.31.10) 

Where is Mullah Omar? Is he alive? Is he in charge? And if not, then who is?

A clear answer to those questions would very likely decide whether the Afghan insurgency stands or falls. Everyone agrees that absolute loyalty to Mullah Omar is what holds the Taliban together. Practically to a man, the group's commanders and fighters say they're fighting for the village cleric they call the "commander of the faithful" and for the restoration of his Islamic Emirate of Afghanistan. "Every Taliban knows that the morale and unity of the insurgency depend on Mullah Omar," says a senior Taliban intelligence officer, asking not to be named for security reasons. "We are all fighting for him." Without their faith in Mullah Omar's divinely inspired leadership, the Taliban would almost surely collapse into a welter of rival clans and factions.

---"This Mullah Omar Show," by Sami Yousafzai & Ron Moreau, Newsweek (8.8.10) 

Are you confused yet? Let me make things more complicated: Afghanistan is really a sideshow here. Pakistan is the primary U.S. national-security concern in the region. It has a nuclear stockpile, and lives under the threat of an Islamist coup by some of the very elements in its military who created and support the Taliban.

---"Beyond the Leaks: Our Pakistan Problem," by Joe Klein, Time (7.29.10)

They were published with fanfare and a flash of excitement, but overnight it dissipated like a puff of smoke in a gentle breeze. The WikiLeaks' leak of 91,000 or so secret documents--U.S. military field reports from Afghanistan--were quickly recognized as much ado about things we already knew. (Except, no doubt, for those Afghan informants whose names were not edited out.)

Highlighted among the disclosures was further evidence of the troubling, ongoing support of the Taliban by Pakistan, and more particularly by its powerful intelligence service, the ISI. Pakistan has continued to consistently and strongly deny the support relationship, but the evidence is too strong to place credence in the denials. 

We can thank our in-country press for what we know about this--and the U.S. military, the Afghan government, and the Taliban, for the access they are given. And by the time the Wiki leaks hit the Internet, some of our journalists were already digging deeper, interviewing Taliban commanders, intelligence, and logistical personnel, talking to experts in think tanks, academe, and government. By early August, the articles quoted above were filed. And the story just gets increasingly troubling, albeit so very logical and practical from Pakistan's viewpoint.

If we can't be certain just how much financial support Pakistan is providing the Taliban, we at least know it is substantial and that they could not sustain their operations on anything like the current scale without it. More, they could not elude the U.S. and Afghan forces were it not for the escape routes and shelter in western Pakistan, which they are permitted. All of which implies strongly that the Taliban could not successfully wage war against the U.S. and Afghan forces without Pakistan's partnership. So, why do we continue to be a party to this public lie, indulge this ruse, with the lives of our soldiers and marines the price being paid?

And partnership is not the right word, but not because Pakistan's role is less than that. To the contrary, less than a partner, even less than a client organization, most of the Taliban appear to operate in cowed subordination to Pakistan's ISI, while pursuing their own goals and agenda as well as they can. If their goal is to restore Mullah Omar and an Islamic state in Afghanistan, they are nonetheless substantially under the control of Pakistan's military and ISI, and therefore must also serve Pakistan's regional interests. And they know it, as they have shared with a number of journalists. From the Time article:

Kilcullen recommended that the committee members read a recent paper by Matt Waldman of Harvard University's Carr Center for Human Rights Policy called "The Sun in the Sky." The paper is astonishing.

From February to May this year, the author conducted separate interviews with nine active Taliban field commanders in Afghanistan and 10 former Taliban officials. The commanders are unanimous in their belief that the ISI is running the show. Some of them received training and protection in Pakistani camps run by the ISI. "[The ISI has] specific groups under their control," one commander says. "The ISI [also] has people working for it within the Taliban movement. It is clearer than the sun in the sky."

And just to be sure their relationship is clear, while providing financial support, escape routes and shelter, Pakistan also rounds up various Taliban leaders from time to time, holds them, interrogates them, indoctrinates them. (It appears the ISI know just where the various Taliban leaders can be found at any time, and can capture them at will.) They are released back to their organizations only when reciprocal assurances have been provided that Taliban operations will function consistent with Pakistan's interests and directions. That's the quid pro quo. From the Newsweek article (7.31.10):

Every Taliban can recite a long list of insurgent leaders who have been arrested in Pakistan or who were killed in Afghanistan with assumed Pakistani complicity...The insurgents say [they were] too brazen, too independent, and too close to al Qaeda for Pakistan's comfort.

That illustrates a central point, Taliban say: the only thing Pakistan can be relied on for is a single-minded pursuit of its own national interest. Some ISI operatives may sympathize with the Taliban cause. But more important is Pakistan's desire to have a hand in Afghan politics and to restrict Indian influence there. "They're neither in bed with the [Afghan] Taliban nor opposed to them," says Stephen Biddle, an analyst at the Council on Foreign Relations. "The reality is that they're in between, which is the rational place for them to be."

The insurgents say they, too, never know what to expect from the Pakistanis. "Sometimes they're angry, sometimes friendly," says a district commander in southern Afghanistan. "Sometimes they want to show us who's boss." No Afghan insurgent can be sure he's safe, says the smuggler, a former Taliban subcommander. After all, he observes, some of the Taliban commanders arrested by the Pakistanis were once favorites of the ISI. "They're like psychopaths," he says. "One minute your friend, the next minute your enemy."

Taliban sources say Pakistan uses catch-and-release tactics to keep insurgent leaders in line. All told, the ISI has picked up some 300 Taliban commanders and officials, the sources say. Before being freed, the detainees are subjected to indoctrination sessions to remind them that they owe their freedom and their absolute loyalty to Pakistan, no matter what. 

But what of the Taliban's unifying raison d'être of fighting for Mullah Omar, and their goal of "restoration of his Islamic Emirate of Afghanistan"? What about the questions posed in the Newsweek article (8.8.10) quoted in the introduction, above? "Where is Mullah Omar? Is he alive? Is he in charge? And if not, then who is?"

Good questions. But no one has reliable answers. Still, intelligently deductive speculation offers some provocative possibilities, including some by the Taliban themselves. From the Newsweek article (7.31.10):

Some leading Taliban even suspect that Mullah Mohammed Omar, the leader and symbol of their jihad, may also be in ISI custody. He has appeared in no videos and issued no verifiable audio messages or written statements since he disappeared into the Kandahar mountains on the back of Baradar's motorcycle in late 2001. "I wouldn't be surprised if the ISI arrested us all in one day," says a former cabinet minister. "We are like sheep the Pakistanis can round up whenever they want." 8.31.10

It would appear likely that Pakistan's ISI does hold Mullah Omar. If he had been killed, and the US or UN forces were involved or knew of it, they would surely have been crowing about it. The death of such a high-value target, one so entwined with the identity and purpose of the Taliban, would be an event they would want every Taliban to know about. It would be a dispiriting setback, a source of disillusionment, and result in disarray among Taliban leadership and fighters alike. Yes, they would want that known.

Since we have heard nothing of his death, that leaves only a couple other possibilities. One, he died among the Taliban, and their leaders are keeping it a secret. Unlikely, for as we just noted, there would have been a scramble for new leadership, and those who aspired and failed would likely have been killed, or the source of friction and division among the Taliban groups. There have been no such reports or intelligence leaked or signaled. And could the diverse groups and interests among the Taliban keep such a thing secret for long? In fact, the broader Taliban leadership appear to believe that he is alive and hold desperately to that possibility, that hope, for they know what his death will mean to the unity of the movement.

So we are left with the likelihood that Pakistan is holding Mullah Omar, the ultimate card in the game of control and direction played with the Taliban. Based on what is known, nothing else makes as much sense. And so the Pakistan government continues to play out the ruse with the US. From the same Newsweek article (8.31.10):

The Pakistanis, for their part, continue to resist U.S. pressure for strikes against Taliban sanctuaries. "Their aim seems to be to prolong the war in Afghanistan by aiding both the Americans and us," says the logistics officer. "That way Pakistan continues to receive billions from the U.S., remains a key regional player, and still maintains influence with [the Taliban]."

(And what of Osama bin Laden? Does the same analysis suggest that the ISI holds Osama bin Laden, or knows where he is hiding? Some have suggested that is the case, including Secretary of State Hillary Clinton who last May embraced that view. But for now, a muted Osama bin Laden at-large likely serves Pakistan's interest in perpetuating a destabilized Afghanistan and maintaining the US commitment to a military presence there.)

The US, impliedly, plays along knowing it has little choice if any semblance of stability is to be maintained in the region. And, increasingly, it appears, the US is coming to appreciate that Pakistan's game plan may be a practical, default answer they can live with, especially if they and the UN can remain active and influential in regional diplomacy, maintain military and political balance, and thereby assure reasonable stability in the region. But what are Pakistan's interests? What motivates the end game they play? From the Time article (7.29.10):

Why on earth are elements of the Pakistani military supporting the Taliban? In a word, India. India is, first and last, the strategic obsession of the Pakistani military. The U.S. has come and gone from the region in the past; the perceived Indian threat is eternal. With the defeat of the Taliban by U.S. forces in 2001, there was fear that the new government in Kabul would be sympathetic to India and provide a strategic base for anti-Pakistan intelligence operations.

And so, despite professions of alliance with the U.S. by Pakistan's then dictator Pervez Musharraf, a decision was made to keep the Taliban alive. A spigot of untargeted military aid from the George W. Bush Administration helped fund the effort. A commander of the vicious Haqqani Taliban network tells Waldman that their funding comes from "the Americans — from them to the Pakistani military, and then to us."

But what of the Pakistan Taliban attacks against Pakistan targets? First, Pakistan does not control all of the Taliban; some groups will not be played in the same way as others. Some are not cowed, and would challenge Pakistan's capability to control them. They understand that Pakistan's interests are not their own; and they have concluded their cause is better off without Pakistani protection and financing if that is the cost of their independence and the integrity of their mission. But they are likely rethinking that after their attacks on Pakistani targets resulted in full-scale retaliatory attacks by the Pakistan army. And, as we've noted, many of those leaders eventually end up imprisoned or dead. Pakistan will do what it takes to make the Taliban leaders see clearly that they cannot win against Pakistan and the ISI with the tactics they use against the U.S. and UN forces. They must understand that they exist only at the forbearance of Pakistan.

And what about al Qaida? Aren't they still a threat in Afghanistan? Not much, apparently. The last US estimates report that there are now only about 100 al Qaida operatives still present in Afghanistan. And it would appear that Pakistan offers no sympathy to al Qaida and would be unlikely to afford them sanctuary. As the Newsweek (7.31.10) quote above noted, some Taliban insurgents were, "too close to al Qaeda for Pakistan's comfort."  Al Qaida is apparently seen by Pakistan much as they are seen by most other countries: a destabilizing threat to their government, social order, and areas of influence. But that does not mean they cannot be abided to the extent they serve Pakistan's purposes. 

To Conclude:

If any reasonable level of confidence can be invested in the articles cited, and the reports and interviews on which they are based, they lead to a credible, more detailed and nuanced understanding of how and why Pakistan is supporting the Taliban--even as they deny it and profess to be America's ally.

Is it all about India? Yes, that troubled relationship is likely at the heart of it all, but ambitions are also implied by Pakistan's strategy. It appears to represent both a national defense strategy and hegemonic ambitions. With its nuclear capability, it aspires to acknowledged regional power and authority. It would also be seen as an emerging international influence, a voice to the world at large. But like Iran, it lacks the international economic, political and cultural credibility to be viewed that way. And Pakistan knows that. They must play out their ruse and effect their strategy one step at a time, waiting for all the pieces to fall in place--waiting for the US and the UN to see the inevitability and acceptability of their designs.

The Time article offers these observations in recognizing the direction of it all:

...the relationship between Pakistan and the Karzai government has warmed considerably. Karzai removed his intelligence chief, Amrullah Saleh, whom the Pakistanis considered an Indian agent. There is talk of a reconciliation deal in which the Haqqani [Taliban] network will stand down militarily. Most important, the Pakistanis' sense of the perceived [India] threat has changed dramatically over the past 18 months. After a series of spectacular terrorist attacks, the army launched a major campaign against the indigenous Pakistani Taliban. More Pakistani army personnel have been killed in this fight than U.S. forces in Afghanistan by the Taliban...

The one thing the U.S. can do to reduce that threat is to convince the Pakistanis that we will be a reliable friend for the long haul — providing aid, mediating the tensions with India; that we will help stabilize Afghanistan; that we will support the primacy of Pakistan's civilian government. Over time, this could reduce the extremist influence in the military and Pakistan's use of Islamist guerrillas against its neighbors. If it does not — well, the alternative is unthinkable.

So, they will satisfy themselves to become the AfPak power and hegemon. They will continue to dominate and manipulate significant elements of the Taliban. They will control their funding, the scope of their ambitions, agenda, their geographic boundaries and social influence. In so doing, they maintain an instrument of significant, if unofficial, regional military and political influence as long and to the extent they feel they need it.

And they could not have fully achieved this end without the Afghanistan War and the U.S. role in it--including a source of ever-increasing funding for Pakistan, some material amount of which is redirected to the support and direction of the Taliban.

After all the dust clears, Afghanistan will likely be a genuflecting regional area of "mixed sovereignty" subordinate to the regional hegemon, Pakistan. The Kabul government will have its limited geographical sovereignty over Afghanistan's major population centers. As to the South and East, the more outlying districts and provinces, some may be under the control of tribal leaders, but the Taliban will likely control many or most, with others under its influence. And the US and its coalition of countries will continue to provide sufficient funding to assure the entire arrangement works. That is to say, with full understanding and commitment, the U.S. will settle on this arrangement as the most stable and sustainable--the most acceptable--in the region.

(See also the concluding section of my earlier essay, "Exiting Afghanistan", and the discussion of a "mixed sovereignty" solution, as described in a recent Foreign Affairs article by Stephen Biddle, et. al.)

5.3.2011 Postscript:

On Sunday, May 1, 2011, based upon new American intelligence, and at the direction of President Obama, an elite American SEAL team succeeded in it's mission to take Osama bin Laden. He was killed in a compound in Pakistan not far from Islamabad, and he had apparently been there for some time.

It is done, finally. Everything's been said, and said again. There is joy, a shared national, even global joy about it--and also relief, but the kind attended by a shade of unhappiness and resignation that it unavoidably took so long.

We were so close to him in those early days in the Tora Bora mountains of eastern Afghanistan. It's been a long time. And for some time we've heard the coninuing, apparently credible reports that Pakistan was often protecting, even directing and financing the Taliban and its leaders, perhaps even keeping Mullah Omar. We dared not think Osama bin Laden, for there was little al Qaeda presence in Afghanistan or Pakistan--and Pakistan couldn't be that bold, right?

But then we found him. He was in a high-walled, large and conspicuous compound without any  detectable  communications connections. It was located in an affluent community some 60 miles from the Pakistan capital, Islamabad, and two miles from their principal military academy. And the residents of that community include many Pakistani military families.

When it was built five years ago, someone might have noticed how unusual it was for that residential area, both in size and configuration. Someone might have noticed how anonymous the occupants, how clandestine, perhaps furtive, their activities--especially given it's location, neighbors, and the reputation of the Pakistani intelligence service (ISI) for knowing all that goes on and who is doing it.

Surely it is apparent why President Obama chose not to inform the Pakistani government or military of our mission to take bin Laden from that compound--and likely take him dead. Congratulations to the intelligence team and the elite SEAL team that made the mission possible and made it a success. 

But should I now revisit and rethink what kind of continuing U.S.- Pakistan relationship remains necessary for regional stability and security--and what kind of relationship is still workable, given our history with this unreliable, mendacious "ally," whose interests and agenda have often proved inconsistent with our own? No, I don't think so. In fact, these revelations are rather consistent with my 2010 understandings and assessment of the ongoing U.S. relationship with Pakistan. So I remain persuaded that my 2010 analysis is likely just as valid, and the end-game realities and prescriptions are likely just as close to what the future will present us.