Improving Health Care, Pt. 3/3

The last two reforms go hand-in-hand: end-of-life counseling and review panels for Medicare/Medicaid. The first of those is not controversial where it’s understood properly. And the facts back it up. “Researcher found that these conversations between patients and physicians led to fewer cases of aggressive care, which saved money and resulted in a far more peaceful death for patients” (Radulovic, 2009). Such conversations save Medicare about  $2,300 per beneficiary. In fact, should 50 percent of people have end-of-life discussions with their doctors, a single year could reduce costs $76 million. “Seventy percent of people request no life-sustaining treatments for themselves when they are dying, and 89 percent desire living wills and other advance directives. Yet only 9 percent have such directives” (Fries et al., 1993). Half of the population dies in hospitals in America, yet 70 percent want to die at home (Thomas, 2009). End-of-life counseling could help get what the patient wants, while reducing costs. It’s a win-win situation for society. I also propose, however, that review boards be established for Medicare and Medicaid patients. These review boards would make decisions about whether or not to give treatment and what level of treatment. The demagogic term for these is “death panels.”

The fact is that end-of-life care is extremely expensive. The elderly in America were 13 percent of the population in 2002, but 36 percent of the health care spending. The elderly cost $11,089 per person per year to the average nonelderly cost of $3,352 per person per year (Agency for Healthcare Insurance and Quality, 2006). In 1999, Medicare beneficiaries in their last year of life were 27.9 percent of Medicare costs. And that will only get worse over the next 20 years as the population continues to age (Centers for Medicare and Medicaid Services, n.d.). Medicare recipients who died in 1978 and 1988 were 28 percent of Medicare costs, showing a remarkable consistency over time. For those who died in those two years, 77 percent of their total Medicare expenditures occurred in their last year of life, 52 percent in the last two months, and 40 percent in their last month (Luce & Rubenfeld, 2002).

All this money is spent to a questionably effective outcome. In one study, patients deemed to have less than 50 percent survival rate for 2 months due to acute respiratory distress syndrome (ARDS) cost $110,000 per quality-adjusted life-year (QALY). Those between 51 and 70 percent 2-month survival cost $44,000 per QALY, and those with a 2-month survival chance over 70 percent cost $24,000 per QALY (Luce & Rubenfeld, 2002). The study further found that if those who had a 2-month survival rate of less than 1% had care pulled, which was 12 of the 2,500 or .48 percent, then the costs of treatment for those 2,500 patients would’ve been reduced by 13 percent (Luce & Rubenfeld, 2002). Another way of looking at that is to say that .48 percent of the patients, who were deemed to have effectively no chance of living even two more months, cost 13 percent of the money. Once again, that’s not everything, but it’s not something to be ignored. Society must decide when to not use so much money for so little outcome.

Even away from death, Gladden asked what the point was in giving a woman in her 80s titanium join replacement, which is expensive, as opposed to another material (B. Gladden, personal communication, October 31). “There is a point where you have to start making calls about resource consumption” (B. Gladden, personal communication, November 1). Gladden compared such boards to transplant boards, saying that those meet on a regular basis in hospitals and decide who’s going to get which organs. Some people die as a result because they’re deemed to be too risky. He questioned the notion that the same logic can’t apply to so-called “death panels” simply because they deal with money instead (B. Gladden, personal communication).

Payment for these proposals is tricky. However, the proposals will clearly cost some amount of money, mainly the affordability credits. The review boards will save the government some money. Another option is taxes on unhealthy lifestyle choices. Placing additional taxes on cigarettes, fatty foods, and other unhealthy habits and activities would generate a good amount of additional revenue. And it would have the added benefit of making those who live unhealthy, and therefore likely cost the system more, pay for more. Rating structure would be another potential way to do this, but segmenting the pool of insurance is always risky, so that shouldn’t be banned as it is in the House bill but it should be kept at a low level. Penalties for not buying insurance would rake in $167 billion for the House bill (Elmendorf, 2009). One could also assume that my proposals would be substantial as well. And without a public option or exchanges, the cost of my proposals would not be as high.

The Democratic and Republican plans are not all that dissimilar. The three things I’ll address are the public option, exchanges, and purchasing insurance across state lines. The problem with the Republican idea of buying across state lines is that every state has its own regulations. And they are vastly different. Families USA put out a report that said five states could cherry-pick the healthiest customers and exclude the others, 35 states have no limits on how much insurers can vary premiums based on health status, eight states allow insurers to exclude coverage for individuals based on pre-existing conditions regardless of how long they’ve had the plan, and the list went on (Hushagen & Fish-Parcham, 2008). Those kinds of variances are too much for interstate purchase. Gladden said the federal government would eventually have to step in and regulate it entirely themselves (B. Gladden, personal communication, October 31).

The exchanges seem like a good idea, but as long as they’re around, people will increasingly use them. And the Democratic idea for funding them is to have employers who don’t provide their employees with insurance pay an eight percent tax (Elmendorf, 2009). With the reduction in administrative costs, some employers will therefore choose to use them and pay the tax, as Pelosi intends (House Committees, 2009). This buildup will mean more price control by the government. Japan controls its prices rigidly, to the detriment of its health care providers. Toshihiko Oba, an ear, nose, and throat specialist in Japan, worked 80-hour weeks for 13 years in the hospital system there for only $100,000 a year (Harden, 2009). Kono Hitoshi, a Japanese man who runs a private hospital, gets paid 450 yen, the equivalent of $4.30, to sew up a cut less than 6 square inches. The result of low costs for consumers is that 50 percent of hospitals are in financial deficit (Reid, 2008). And that’s not even taking into account the loss of a profit motive for innovation, which Gladden agrees has been a major factor in US health care, saying that American innovation in the health care industry has helped the world over (B. Gladden, personal communication, October 31). In 2006, research and development by pharmaceutical companies cost $43 billion. Each new medicine costs $1.3 billion to research, develop, test, and get through FDA approval (“Year in Review” 2008).

The public option may lead to a monopolized market. “I think it’ll require them [health insurance companies] to be more efficient or leave the industry” (B. Gladden, personal communication, October 31). It’s possible that we will one day need a public option, which Gladden felt would help a little, but for now even a weak version shouldn’t be implemented (B. Gladden, personal communication, October 31). Once you have something like that, it’s politically impossible to remove. So for now, I oppose the public option and the exchanges.

Improving Health Care, Pt. 2/3

Another item on the list of modifications is to end the anti-trust exemption health insurer’s have. Perhaps they needed it 60 years ago, perhaps not. But the $800 billion in waste, 18 percent ($144 billion) of which is from administrative inefficiency and redundant paperwork, argues they don’t need it anymore (Fox, 2009). The House bill does this, and Speaker Nancy Pelosi argues that it “shields these insurers from liability for fixing prices, dividing up territories, or monopolizing their market” (House Committees, 2009). Gladden said that he’s not sure how much of a difference ending the exemption would make, given how heavily regulated the industry is (B. Gladden, personal communication, October 31, 2009). But it can’t hurt. And there should be a solid reason to exempt someone from a law. There isn’t one here, so their exemption should be stripped.

Price transparency is something the health care industry has essentially none of. The degree to which it’d help is questionable. After all, most health care expenditures in the US are not out-of-pocket. They are, in fact, at 12.6 percent, one of the lowest in the developed world (Barnes, 2009b). Thus more careful shopping may not ensue. But it still, once again, can’t hurt. Consider it experimental. This reform would cost very little to implement, and it just may help. “By making the full details of the U.S. health care cost structure available to public scrutiny, it would, at last, create a truly open marketplace for health care, in which the pricing policies of medical institutions and the reimbursement policies of insurers would be laid bare for the entire community to sift through, analyze, and debate” (Flippin, 2009). The expansion of Health Savings Accounts might further help the effects of this reform. The way to achieve this, removal of legal obstacles to their creation was advocated by the co-founder and CEO of Whole Foods Market Inc. in the Wall Street Journal (Mackey, 2009). Putting people in charge of their expenses would inevitably make them more aware of what they’re paying, if price transparency is instituted as well.

Health insurance co-operatives are another example of experimental reform. Congress provides the start-up loan to states to dedicate to their creation, as the House bill does, and it pays for itself from there (House Committees, 2009). These haven’t been so successful on a state level, as is consistent with state attempts at reform (Barnes, 2009c). When I asked Bob Gladden about this, and why we can’t leave reform to the states, especially considering that that’s where the bulk of the regulation is, he responded that it’s a question of resources, which the federal government has much more of (B. Gladden, personal communication, November 1). The government has a much larger budget to operate with, and it can engage in behavior that, temporarily or not, increases its deficit. This is in comparison to the fact that almost all states are legally bound to balanced budgets. States are in no shape to try to take on more than one ever-so-tiny and essentially unnoticeable change at a time. With the political will to do it right now, the federal government can and should mobilize its resources (B. Gladden, personal communication, November 1).

The next step is one of the more controversial: individual mandates. It is unfortunate, but it must be done. Especially if pre-existing conditions are no longer a factor in health insurance. “Insurance works best where everyone is thrown into a single pot and those who need care get it paid for” (B. Gladden, personal communication, October 31). The people who choose not to buy insurance tend to be, of course, healthy. They’re skipping out on this pool. Which is itself, not a problem. But the uninsured cost the rest of society money. “There is a point in which everyone has the right to access the system, therefore they should have to pay to access the system” (B. Gladden, personal communication, October 31). Gladden pointed out that hospitals are legally required to make you at least stable should you need their services because of, say a heart attack in the street. Now, you could theoretically get rid of that law. But, not only is that politically impossible to do in the first place, the moment it was done, there’d unquestionably be stories about people who had insurance, but there was a communication error between the hospital and the insurer, or some files were misplace, and the person died while waiting for the hospital to confirm he/she could pay for it. Then the law would be put back into place. Is health care a right? I’d say no, because it’s an entitlement. But the reality is that there is little choice but in treating emergency care like a right. So, therefore, I propose an individual mandate on a basic level. That is to say, a sort of catastrophic insurance. Republicans have suggested that it’s unconstitutional, and they’ve rejected comparisons to auto insurance (Adamy & Hitt, 2009). But the comparison to auto insurance is valid, because in this day and age the vast majority of Americans need cars. Sure, you can technically get along without it, but not really. And the government is empowered to protect rights. The rights of the uninsured will be violated by making them purchase insurance. However they are currently using other people’s money for their own health care. The system right now is violating the same right to keep what you earn, only it’s violating it less per individual in a much broader manner. A mandate is an example of a concentrated cost for a distributed benefit, both in regard to money and in regard to rights. But, a more extensive mandate should not be required. Gladden referred to insurance like what HMOs provide as “glorified savings accounts” and compared the idea of health care insurance to other types of insurance. Health care insurance, he said, had taken on a different culture. Insurance is supposed to be something you buy and hope you don’t ever need to use, like car insurance or fire insurance for one’s house (B. Gladden, personal communication, October 31). The numbers for the concentration of spending in health insurance illustrate that, while the culture is changing, health insurance is still used like other insurance. Five percent of the population consumes nearly half of the health care expenditures (47.7 percent), 1 percent of the population consumers 21.1 percent, the top 20 percent of users consume 79.8 percent, and the bottom half only consume 3.2 percent (“Health Care Costs,” 2009). Those numbers are also a clear indication about the way pooling works in the insurance industry and why the healthy uninsured citizens are needed in the pool.

If insurance is mandated, which it should be, then that also means the government must make it affordable. “Affordability credits” are part of the House bill, on a sliding scale based on where a household’s income is relative to poverty (House Committees, 2009). These should be offered through state governments and based on an individual state’s poverty level. They should not, however, be offered through any type of exchanges. And they should only be sufficient to allow the people in question purchase the sort of catastrophic coverage mentioned in the previous paragraph. If people are still unable to afford further coverage, they can make use of charities. There are still food insecure people in this country, and homeless people. Emergency care may be granted as a right, but annual doctor’s visits are not. There are charities out there for further care. The National Association of Free Clinics deals with over 1,200 free clinics across the country (“Who We Are,” n.d.). Let those expand with private money, government resources need not be used to fund or provide for the “glorified savings accounts” beyond those on Medicaid.

Improving Health Care, Pt. 1/3

For one of my classes I had to write a paper on what I propose for health care reform, backing up my own ideas and explaining what’s wrong with congressional ideas if I chose not to back the plans in Congress. Here is that paper, in three parts, with hyperlinks instead of a works cited page. I’ll post part two Tuesday and part three Wednesday.

The health care reform debate in America has consumed the nation and its media. President Obama, Democrats in Congress, and Republicans in Congress are all supporting substantial changes in one form or another to the health care system. In September, a CBS/New York Times poll found that 51 percent of Americans think the health care system needs fundamental changes, and 27 percent think the entire system needs rebuilt (CBS, New York Times, 2009). I do not advocate that. The system has come under a lot of attack from both sides of the aisle. But it does not need to be fixed, overhauled, or a revolution. It needs minor changes and modifications. As Bob Gladden has said, “There will be no revolution…it will require a journey. There’s not going to be a transformation” (Vice President of Information Management and Analysis at CareSource Bob Gladden, personal communication, October 31, 2009). The language of politicians may be used to rile up their base, Gladden suggested, but he made clear that it was not reality.

The problems of health care in America have been overstated. Fred Barnes blasted the World Health Organization’s ranking of America as the 37^th best health system in the world, pointing to some of its ideological assumptions that cause it to include such things as “financial fairness” when ranking countries (Barnes, 2009b). And the number of uninsured is itself, not wholly accurate. An oft-quoted number is that there are 47 million uninsured. But, using 2004 numbers, it is apparent that that doesn’t tell the whole story. Of the 44.6 million without insurance in 2004, 24.7 percent were eligible for already-existing public coverage, 19.6 percent could afford coverage, and only 55.7 percent, or 24.9 million, of those 44.6 million uninsured needed assistance to get health insurance coverage (Dubay, Holahan, & Cook, 2006). There were 301.483 million people in the United States in 2008, of which 46.34 million were uninsured (U.S. Census Bureau, 2009). If one assumes that the percentage of people who needed assistance remained constant, then 25.8 million need assistance, which is only 8.56 percent of the population at large. Furthermore, those numbers include non-citizens. That is to say, they include legal residents who are noncitizens. In 2006, 10 million, or 21.6 percent, of the uninsured were noncitizens (Fronstin, 2008). That would translate in 2008 numbers, assuming once again that the 21.6 percent figure remained constant, to 10.01 million people.

However, it is easy to see that the system is not perfect. Those people are uninsured, and the uninsured consumed an uncompensated $34.5 billion in 2001 (Hadley & Holahan, 2003). As the number of uninsured has gone up, so has that number, undoubtedly. The health insurance industry is incredibly regulated. Gladden stated that the regulations on utilities pale in comparison to the regulations Medicare and Medicaid, pointing to their frequent (often quarterly) and extensive reports to the various state governments and the fact that they even have to get their rate structure approved by state governments (B. Gladden, personal communication, October 31, 2009). Reform is complicated, though. There are many aspects to health care that have to be examined for the nation to continue on what was referred to as a “journey” by Gladden. “This is an industry that has multiple tentacles to it. Anyone who says there’s the problem and points to a single thing is not paying attention” (B. Gladden, personal communication, October 31, 2009). With that in mind, I do propose several ideas to improve health care in this country. The current congressional/presidential plans will be addressed throughout and comprehensively at the close of this paper.

The most obvious reform is the elimination of “pre-existing conditions.” The CBS/New York Times poll referenced earlier found that 80 percent of Americans approve of that particular reform, with only 16 percent disapproving, with Republicans having the highest disapproval at a still-paltry 25 percent (CBS, New York Times, 2009). That means that there’s certainly going to be no political problem with it. And this is something the government must step in to do. Gladden’s response to a question about pre-existing conditions in the interview was to play out a scenario wherein a major company sought to be a “good corporate citizen” and cover them. He said they’d be lauded in the press initially, and they’d see more business in the short term. But the reason companies don’t cover people with pre-existing conditions is because they’re more expensive. So Gladden stated that, in the long term, premiums would go up and the company would go under as people without pre-existing conditions flocked to the lower premiums of its competitors (B. Gladden, personal communication, October 31, 2009). So the government must step in, and the people must support them.

Medical malpractice is another reform that is needed. Opposition to this in the public is even lower than opposition to the pre-existing conditions reform. Only 11 percent of Americans oppose putting limits on awards in malpractice suits (CBS, New York Times, 2009). There are other reforms that are possible, of course, than simply limiting damages. One of which is to eliminate all noneconomic damages awarded. No more “pain and suffering” rewards. But the cap is a good place to start. It’s difficult to quantify just how helpful said cap will be. This is due to the fact that doctors, as a result of medical malpractice concerns, practice defensive medicine. Gladden described this succinctly as over-prescribing, over-testing, and over-diagnosing (B. Gladden, personal communication, October 31, 2009). Ninety-three percent of doctors in six specialties with high risk of litigation (emergency medicine, general surgery, orthopedic surgery, radiology, and obstetrics/gynecology) reported practicing defensive medicine. Of those 93 percent, 43 percent said they used clinically unnecessary imaging technology. And, more frighteningly, 42 percent reported that from May 2000 to May 2003 (the three years leading up to the study) they had done things such as eliminating procedures prone to complications, like trauma surgery (Studdert et al, 2005). The conclusion of the abstract put it simply; “Defensive medicine is highly prevalent…with potentially serious implications for cost, access, and both technical and interpersonal quality of care” (Studdert et al, 2005). Fred Barnes reported that medical malpractice premiums are increasing at a rate of 12 percent annually (Barnes, 2009a). Medical malpractice will not, of course, take care of everything. But there is no reason not to engage in reform except for political reasons. Barnes slams President Obama and the Democrats for being weak on trial lawyers, and claims that if they’re serious about cutting costs they’d support something which reduces costs by a minimum of $100 billion dollars and possible twice that or even more (Barnes, 2009a). Reuter’s numbers are even more significant, claiming that $200 to $300 billion, 37 percent of the total waste, is attributable to defensive medicine (Fox, 2009).

War of Necessity

On Veteran’s Day, Armistice Day, it seems appropriate to discuss a foreign war. The War on Iraq’s been off the radar lately, but the War in Afghanistan has been all over the news. When I first heard that President Obama was going to review the Afghan strategy, I didn’t fully grasp what was meant by that. I was figuring one week later, two weeks at most, he’d announce to the American public and the world at large what he intended to do about Afghanistan. After all, he had unveiled a new strategy for Afghanistan and Pakistan last spring, hadn’t he? But this more recent review began two months ago.

That puts the total months of review of Afghanistan policy up to four months of the past ten months. Reviewing a strategy is a good thing, and so is being fully aware of all the options before making a decision. The review is something I approve of. But how is it that liberal pundits are surprised to hear Republicans complaining about what they call President Obama’s dithering, or his wait-and-see policy? I mean, how can they honest-to-God claim at this point that Republicans who attack the president are simply “playing politics” and have no real issue here? All this review time is not going to look simply like really intense “thoughtful consideration” to people who aren’t predisposed to like anything President Obama does. And as for people predisposed to hate anything President Obama does, well, that should be self-explanatory. I’m not even necessarily against his delaying up until now, if that’s all it is. Waiting to see who our partner in government is over there is perfectly reasonable. But we now know for sure it’s Karzai. There’s no surprise in that, he was always expected to win. It was a more fraudulent election than we’d like, sure. But to think anything else will happen in a country which has been a democracy for so short of time is naive. So I don’t see what he’s waiting for here.

And, if he intends to increase troop levels, he’s only hurting himself. That’s why I’m inclined to believe that claims of review are legitimate. In March an article in The Guardian said, “An official said yesterday that Obama’s planners thought they had about 12 months to show measurable progress in Afghanistan before public support would wane and the policy turn into a Democratic-Republican political issue.” Well, they seem to have underestimated how quickly public support erodes for a foreign war with casualties. And, with the War on Iraq winding down, Afghanistan’s casualties have been higher than Iraq’s these past few months. Either way, the longer they wait, the harder it will be to initiate a surge there.

One of the things that worries me about this whole situation is the language of the administration in the last month. It has been one which is clearly intended to separate out Al Qaeda and the Taliban in the minds of the American people. They’ve made clear that we are not going to be doing any “nation-building” over there, and that our goal is not the Taliban. But rather, our goal is Al Qaeda. No one will contest that Al Qaeda is our main enemy. But the problem with a strategy that focuses on Al Qaeda and essentially ignores the Taliban is that you can’t defeat Al Qaeda by force of arms. We could train and arm every able-bodied man and woman in the country and send them to destroy Al Qaeda, and it will be a fool’s errand. President Obama said in March, “I want the American people to understand that I have a clear and focused goal: to disrupt, dismantle, and defeat al Qaeda in Pakistan and Afghanistan, and to prevent their return to either country in the future.” That’s a fine goal. But, since then, his language has dropped the country-specific rhetoric and has focused on the idea of disrupting, dismantling, and defeating al Qaeda. That is not okay. They key is not to destroy al Qaeda, the key is to deny them Afghanistan and Pakistan as safe havens. Al Qaeda will never be destroyed. But, while they don’t have a secure base of operations they are far less dangerous to us than with one. And there should be no misunderstanding…If the Taliban take power in Afghanistan again, Al Qaeda will return.

This is not a war like other wars. I’m not the first to say that. On Meet the Press David Gregory said that, and his guests agreed. But then, five minutes following that, he had a chart put up on the screen that compared the number of months we’ve been in Afghanistan versus Iraq versus WW1 versus WW2 versus the American Revolution, etcetera. There’s a clear lack of understanding on the part of the media, the politicians, and many of the “experts” in regard to the implications to be drawn from the common understanding that this is not a war like other wars. The ceaseless comparisons to Iraq in 2007 and Vietnam 40 years ago also illustrate this problem. Afghanistan is a place with mountainous terrain which does, like the jungles in Vietnam, limit the advantages of American military superiority. And, like Iraq, it is a fractious country filled with a good deal of anti-American sentiment. But there’s so much more to this fight.

For one, Afghanistan has never truly had a central ruling government. The Taliban rule was far from absolute before the US invasion in October 2001, and the rule of the various governments before that, including the Soviet-backed communist government, was also limited. Whereas Iraq had, for all his brutality (including the genocide of the Kurds) Saddam Hussein to hold them together as one nation.

Second, the Taliban aren’t backed by a world power (like North Vietnam and the Viet Cong were) or even a regional power (like the Shia militias in Iraq, such as that led by Muqtada al-Sadr, were and are). And God knows Al Qaeda and bin Laden aren’t backed by a major power. When they ruled Afghanistan, they were recognized only by Pakistan. And that was as much because they’re next-door neighbors and Pakistan is always worried about the lawlessness of its border with Afghanistan as anything else.

Third, Afghanistan is a landlocked country, instantly decreasing its legitimate wealth. This is a problem of geography and can’t be helped. But that doesn’t mean we should ignore its effect. It’s directly tied to my fourth point, which is where I’ll end this list though there are more reasons Afghanistan is different. The people in power in Afghanistan, legitimate and otherwise, get lots of money through the opium trade. And I mean a lot. They produce 95% of the world’s poppy. Ninety-five percent. This is the main problem with the recently-approved plan to buy off our Afghan enemies. The Sunni Awakening worked in Iraq for a couple of reasons. One: most of the people who switched sides were formerly in the Iraqi military and simply fought in a militia because fighting is what they did. They had no other trade. Two: as a result of the first reason, they needed money for themselves and their families. Where it came from mattered less than that they got it. The people of Afghanistan can get loads of money through an illegal trade. They’re naturally hostile to outsiders, especially those in the border mountain region that make up the Afghanistan-Pakistan border. And they’re not former military for a legitimate country ruler. The government pre-US invasion was run by the Taliban, a principled fighting organization. You can’t just pay them all off nearly as easily.

The options President Obama is choosing from are varied. He won’t pull out of Afghanistan, that’s not even on the table. But the plan advocated by Vice President Biden is to use targeted attacks to take out the terrorists. On its face, that sounds nice. Little risk to our troops and we can work on destroying al Qaeda without worrying about all this extraneous nation-building. What with low public support for the war and a corrupt government in Afghanistan, this must surely look tempting to the president. But the problem is that it simply won’t work.

My International Relations professor explained counterinsurgency options like by describing a range of options. On one extreme is the scorched earth policy. Destroy the insurgents and any individual, family, or village you think is aiding and abetting the insurgents. The Soviets used this policy in Afganistan during the ’80s. No politician in this country is advocating its use.

On the other side of the spectrum is the hearts and minds policy. This is what we used to great success in Iraq. It’s the policy of getting to know the people you’re protecting (or occupying, I guess, depending on your viewpoint) and getting them to like you at least enough to A) stop aiding and abetting the insurgents and B) provide you with intelligence in regard to the whereabouts of said insurgents. Police forces across America have also used this tactic, such as in my hometown of Palatine, IL. To implement it, you need lots of soldiers, and they need to spend a considerable amount of time walking around on the streets and talking with residents. In that part of the world, drinking tea with the residents has great cultural importance and has been used as part of this tactic. This tactic does, however, lead to an initial spike in casualties as soldiers spend more time outside of armored vehicles. In the long-term, though, this is the only tactic proven to work.

The middle-ground tactic that Vice President Biden advocates is referred to as the search-and-destroy option. The predator drone strikes in Pakistan are an example of this. The Israelis have also been using it for years. The problem with this option is simple math. You can’t just assassinate terrorists with sniper rifles (actually in this country, we’re rather queasy about assassinating terrorists period. Odd, though, that this tactic is so supported and it has little difference from assassination). Rather, we use the drones to drop precision bombs on our enemies. The Israelis drop bombs, use warships, and whatever else they like. The fact that Israel uses this tactic regularly shows that simple assassination doesn’t work, since, after all, Israel does assassinate people. When that bomb is dropped from the drone, the terrorist will likely be killed. But so will many others. When the US killed al-Zarqawi in 2006, we killed six others, not all of whom were even adults. Now anyone related to one of those people, or who was a friend of one of those people, has reason to hate America. It’s likely that between the relatives and friends of those six people, there’s more than one person who is willing to take up arms against the United States who wouldn’t have before the attack. Right there, we had a net gain in the number of enemies. That means that for certain people, like al-Zarqawi, or bin Laden, or al-Zawahiri, it’s worth doing. But you can’t defeat the enemy via this strategy. And the death of bin Laden, while tragic for their movement (and gleeful for us) would not actually change much anyway. So you can’t count on ridding the world of bin Laden and al-Zarqawi and suddenly al Qaeda crumbles.

Therefore, we must do what General McChrystal asked and give him the 40,000 more troops. We should encourage our NATO allies to give more soldier as well. The president claimed during the campaign that this was a war of necessity. His tough talk on Afghanistan and Pakistan is the main reason attacks on him as being weak on national security were unsuccessful. He said in mid-August that the War in Afghanistan “is fundamental to the defense of our people” in the same speech he declared, “I will not hesitate to use force to protect the American people or our vital interests.” His “review” is bordering, many say passed, the point where we could consider it hesitation. It’s time for this review to come to a close and him to send in more troops. The Taliban maintains a permanent presence in 80% of Afghanistan. The 40,000 is a minimum start. And my understanding is that that’s all General McChrystal intended it to be. Enough to stop Taliban gains. Twice that may be needed, and President Obama must be prepared to make the choices that could very well cost him the presidency. Especially in matters of foreign policy, which is too complex for anyone who doesn’t closely follow the news to have a prayer to understand.

Public opinion is fickle, and suspect in foreign policy. Everyone’s seen the depressing numbers on how few Americans can find Iraq or Afghanistan on a map. And many can’t even find America on a world map. Foreign issues are incredibly complex, and the president of the United States, commander-in-chief of the US armed forces, cannot make decisions on the basis of public opinion. If this is a war we must win, listen to the generals and give them what they want. If it’s not, bring our troops home. His tendency to compromise could, on this issue, cost American lives to no gain. Send in the soldiers. If the Taliban return to power, the past eight years will have been for naught and we will be less secure. Secretary Clinton, VP Biden, and President Obama have all said in the past a returned Taliban inevitably means a returned Al Qaeda. So let’s forestall that scenario. Republicans will back him, and Democrats wouldn’t dare withhold funding and play chicken with the lives of our soldiers. The review must end soon, and more troops must be sent.