So I’m Blue in the Face

Andy doesn’t get it:

Moreover, a wholesale shifting of healthcare from the private to the public sector simply means replacing rationing by wealth with rationing by number, and a drastic decrease in individual freedom on both sides of the medical equation. You’d replace insurance company bureaucrats who deny care with government bureaucrats who deny care. Removing the financial incentive from doctors simply means they will provide sloppier treatment. They’re not saints. They’re human beings. And slashing the profit motive from the drug companies will simply mean fewer new drugs for fewer illnesses. This is the trade-off the left will deny till they’re blue in the face. But it’s a real trade-off.

But for the most part these trade-offs are not happening elsewhere. So why would they happen here if they are not happening in, say, France?

In one part of Sicko a doctor — I can’t remember if he’s British or French — explained that his income goes up if his patients get healthier. Meaning, if his records show he is providing patients with good preventive care, as opposed to just writing prescriptions, he gets bonuses. Here, doctors get paid for not treating people.

Patients in those nasty foreign countries like Canada actually have shorter waiting lines in emergency rooms than they do here. They get better general care, which is why they live longer and have lower infant mortality rates. Patients are not being denied care because of some technicality in their private insurance contracts. People are not being driven into bankruptcy by medical bills. Other nations’ plans are not perfect, but nearly all of ’em are a whopping huge improvement on what we’ve got.

As far as the “fewer drugs for fewer illnesses” line — what’s actually happening is that highly subsidized American Big Pharma cranks out tons of boutique drugs for boutique illness (toe rot; restless leg syndrome) or “new” drugs advertised as breakthrough but which usually are just minor tweaks to the old drugs, or perhaps not as good as the old drugs. “Life-saving” often means “terminal patients get one more month.” That sort of thing. I’ve written about his before; see “Demand Supply” and “Unhealthy Care.”

Andy continues,

The European health systems have, of course, been free-riding on private U.S. drug research for decades. Name a great new drug developed in Europe these past ten years. Their own pharmaceutical industries have been decimated by the socialism Moore loves (and many of Europe’s drug companies have relocated to the US as a result). But I fear the left is winning this battle; and the massive advantages of private healthcare are only appreciated when you lose them.

European drug companies move here because they make money like bandits here. But let’s play Andy’s game. Name a great new drug developed in Europe these past ten years. Then name a great new drug — and I mean really great, and really new, not just advertised as great and new — developed in the United States these past ten years. Most of the “new” drugs I know of coming out of America are either variations on old stuff, drugs that had to be withdrawn from the market after patients developed nasty side effects, or drugs that really don’t deliver all that much — one fabulous “new” drug I discussed here increased overall survival rate in cancer patients by 4.7 months, for example. That’s nice, but that’s the “trade off” Andy doesn’t want to give up for single payer health care. I’m not convinced.

Kevin Drum writes,

This business about America providing all the world’s pharmaceuticals is a common trope on the right, but it’s absurd. There are more biotech startups in Europe than in the U.S. Pfizer is targeting Japan as one of its biggest near term growth opportunities (and Japan is also a major source of new biotech development). And plenty of pharmaceutical research is done outside the U.S.: The #3 pharmaceutical company in the world, GlaxoSmithKline, is British. The #4 company, Sanofi-Aventis, is French. The #5 company, Novartis, is Swiss. #6, Hoffman-La Roche, is also Swiss. #8, Astra-Zeneca, is Anglo-Swedish. Their combined R&D spending is slightly higher than the American companies that make up the balance of the top ten.

Now, what is true is that American capital markets are both bigger and generally friendlier to startups than European capital markets, which means that small biotech companies often migrate to the United States in order to get funding. My sense is that Europe is improving on this score, but in any case this has nothing to do with the state of European healthcare. What’s more, an enormous amount of basic research is done in American universities and the NIH, most of it publicly funded. This speaks well for our system of higher education, but doesn’t really say anything about our healthcare industry, which is famously hesitant to invest in genuinely innovative (but chancy) new ventures. Ironically for big pharma’s cheeleaders, it turns out that America’s titans of capitalism mostly prefer to leave the risky stuff to the feds.

No Parades

E.J. Dionne writes in today’s Washington Post:

Quietly, the real debate over Iraq is beginning.

It’s not about whether the United States should pull out troops. That is now inevitable. The real challenge is to figure out the right timetable for withdrawal, whether a residual force should be left there and which American objectives can still be salvaged.

The Bush Administration, by its own choice, is not taking part in this debate. The Bushies are still playing kick the can, moving the deadlines for making choices ahead into next year, when they hope to run out the clock. If they can’t have victory, the next best thing for the Bushies is to keep the war as it is until January 21, 2009. That’s the first day of work for the next administration. Then it’s somebody else’s war to lose.

E.J. Dionne continues,

The facts are these: We do not have enough troops to commit to Iraq to turn things around militarily, and the political situation is too fractured to give rise to a sudden burst of cooperation between Shiites and Sunnis.

Colin Kahl, a nonresident fellow at the Center for a New American Security (CNAS), a middle-of-the-road think tank that launches formally tomorrow, sees the American saga in Iraq as the Goldilocks story in reverse. We sent a large enough contingent of troops to give the United States responsibility for security but too few to keep order. “Not hot enough, not cold enough, just wrong,” Kahl says.

Time is running out, because most Americans no longer believe the administration’s promises that the commitment in Iraq will turn out well if only we are patient. This is why we need to begin planning our withdrawal now rather than waiting until the Army and the reserves hit the breaking point.

More than two months ago a “WaPo on the web” writer, William Arkin, wrote that the military is at the breaking point. So we can’t wait much longer.

For that reason, and the fact that political support for the war continues to erode, I do not believe the Bushies will be able to kick that can into January 2009, as they hope.

Yesterday Republican Sen. Richard Lugar of Indiana urged the president to change course in Iraq “very soon.”

[CNN] Lugar, the ranking Republican on the Senate Foreign Relations Committee, also sounded a pessimistic note on the prospects for internal political progress in Iraq.

He said he sees “no convincing evidence that Iraqis will make the compromises necessary to solidify a functioning government and society, even if we reduce violence to a point that allows for some political and economic normalcy.”

The senator said continuing military operations in Iraq were putting a damaging level of stress on U.S. forces, “taking a toll on recruitment and readiness.”

“The window during which we can continue to employ American troops in Iraqi neighborhoods without damaging our military strength, or our ability to respond to other national security priorities, is closing,” he said. “The United States military remains the strongest fighting force in the world, but we have to be mindful that it is not indestructible.”

If Lugar can say these things without being struck by lightning or abducted by aliens, other Republicans may be emboldened to follow.

Lugar is not yet talking about a “full” withdrawal, however.

Despite his call for a course change, Lugar said he did not support calls by some Democrats for a complete U.S. withdrawal from Iraq, which he said “also fails to meet our security interests.”

Rather, he said a “downsizing and redeployment of United States military forces to more sustainable positions” — in rural locations of Iraq, Kurdish areas or possibly Kuwait — might better serve American security interests.

Kuwait would make it an “over-the-horizon redeployment,” I believe.

Lugar also warned the president that failing to pay heed to domestic political opposition to the war, especially with a presidential campaign approaching, would result in contentiousness that would “greatly increase the chances for a poorly planned withdrawal from Iraq, or possibly the broader Middle East region, that could damage United States interests for decades.”

Translation: Republicans soon will have to choose between propping up Bush’s stupid ass and winning next year’s elections.

Back to E.J. Dionne:

Oddly, President Bush has more of an interest in this than anyone. “The more time passes, the more our options narrow,” says Kurt Campbell, the chief executive and co-founder of CNAS. “Left unchallenged, the president would fight to exhaustion, and we can’t afford to fight to exhaustion.”

E.J. — He doesn’t care. All that matters to Bush is not having to say he lost.

Here’s what’s going to happen: The White House will continue to kick the can and pretend everything in Iraq is going according to plan. But sometime — maybe not September, but before the end of the year — enough Republicans will switch sides on the war that a veto-proof majority will at least seem within reach. At that point the Bushies will scramble to come up with a “new” plan that is either (a) a desperate attempt to redefine the status quo to make it more palatable; or (b) a plan to withdraw some or even most combat troops, accompanied by some bullshit about how this had been Bush’s plan all along, and somehow Democrats are responsible for drawing the war out and making the troops stay in Iraq so long.

Both plans a and b will involve a greater emphasis on the permanent bases. And no, I don’t want permanent bases in Iraq, either. But if some time this fall Congress settles on a troop withdrawal plan that includes permanent bases, remember that such a plan doesn’t mean there really will be permanent bases.

When the last of the combat troops left Vietnam in March 1973, official U.S. policy was that an American “presence” would remain in South Vietnam, in the form of military advisers and permanent U.S. installations, guarded by Marines. Two years and one month later, the last Americans were airlifted out of Saigon.

In effect, once the combat troops were withdrawn almost everyone, including the politicians, just plain lost interest in Vietnam. We had Watergate to keep us entertained, of course. But Congress (in a big reversal from what most of the congress critters had promised to do) stopped throwing money at the South Vietnamese government, and North Vietnam was able to take over, and virtually nobody in the U.S. bleeping cared. Overnight, the nation went from arguing about Vietnam 24/7 to “Vietnam, who?”

That doesn’t mean the same thing will happen with Iraq. However, maybe it’s OK to deal with withdrawal of combat troops separately from the permanent bases issue. Certainly, right now it seems most politicians of both parties in Washington are talking about permanent bases. Some, like Lugar, who are beginning to make noises about withdrawing combat troops seem to think of permanent bases as a condition for withdrawing combat troops.

Once combat troops are withdrawn, however, events on the ground in Iraq and political/economic dynamics here in the U.S. could soften support for permanent bases rather quickly. Or not. Depends on a lot of stuff that hasn’t happened yet. Could go either way. I personally would not insist on an absolutist, everybody-out-at-once position if it means combat troops stay in country longer while we haggle in the U.S. It’s OK to get the combat troops out first, then deal with the bases.

See also: The plan from the Center for American Progress.

Update: Voinovich joins Lugar.