(photo by Marco Vossen)

White House press secretary Robert Gibbs told Reuters (via TPM) today that it will be at least another week — in other words, after Thanksgiving — before President Obama announces his new strategy for Afghanistan (not to be confused, of course, with his previous new strategy from earlier this year).

Meanwhile, though, Speaker of the House Nancy Pelosi wasn’t waiting to reiterate her assessment of the situation (also Reuters via TPM):

Afghan President Hamid Karzai is an “unworthy partner” who does not deserve a big boost either in U.S. troops or civilian aid, U.S. House of Representatives Speaker Nancy Pelosi said.

Pelosi, a skeptic on sending more troops to Afghanistan, also said in an interview with National Public Radio aired on Friday that there was not strong support among her fellow Democrats in Congress for “any big ramp-up of troops” to oppose resurgent Taliban forces.

She told NPR she had asked fellow Democrats to give President Barack Obama room to decide his Afghan strategy, which is expected to be announced in the coming weeks. Once Obama, also a Democrat, announces his decision, lawmakers would “not be shy” about responding, she said.

“The president of Afghanistan has proven to be an unworthy partner. We cannot fund a mission where we don’t have a reliable partner and where whatever civilian investments we want to make, which are so necessary, will be diverted for a corrupt purpose,” Pelosi told NPR News’ Morning Edition.

“How can we ask the American people to pay a big price in lives and limbs and also in dollars if we don’t have a connection to a reliable partner?”

Pelosi’s comments are right on target.  Karzai is exactly what many observers feared Iraq’s prime minister Nouri al-Maliki was — a corrupt, incompetent leader who would use past American rhetoric (and a general reluctance to admit defeat) to hold U.S. troops hostage indefinitely to prop up his failing regime.

As it turned out, Maliki may be crooked and inept, but at least he had the wherewithal (and was sufficiently distrustful of U.S. motives) to sign an agreement to gradually ease us out of the picture.  Karzai hasn’t been nearly as generous, leaving Obama trapped in what has become an unwinnable war on behalf of a resented foreign occupation — as described vividly by recently resigned diplomat Matthew Hoh, as well as leaked cables by U.S. ambassador Karl Eikenberry.

Apparently, the remaining pipe dream on the hawks’ side is that if we can just scrape up another 40,000 troops, we can somehow put the clamps on the Karzai government’s corruption and restore public trust in what we’re doing.  Which, I suppose, would be great if we had the 40,000 troops to spare, if the leap from sending the troops to winning hearts and minds wasn’t so heavily based on wishful thinking, and if it wasn’t already so late in the game.

The hardest thing for many hawks to accept about Iraq was that after several years of missteps (including the initial decision to invade), there was no mission left that could be accomplished, and no opportunity for a do-over.  Obama’s long pause as he ponders Afghanistan suggests that he’s struggling with the same realization there as well.

Bill Clinton told FDL’s Eve Gittelson that it would be problematic for him to attend a free medical clinic being held in Little Rock, Arkansas tomorrow because MSNBC’s Keith Olbermann had “politicized” the event.” He indicated that some were turning the event into a primary kickoff against Arkansas Sen. Blanche Lincoln.

Eve ran into Clinton Thursday in the gift shop of the Clinton Library. She’s in Arkansas covering the Keith Olbermann’s free clinic event, organized by the National Association of Free Clinics. The former President is in town for the 5th anniversary of the Clinton Library.

Eve had met Clinton before, most recently at the Clinton Global Initiatives event in September, and President Clinton remembered her.

Eve told Clinton that she was in town for the clinic, which at least 1,500 patients are expected to attend. Clinton said that he had heard about it.

“I really wanted him to come,” she said. “So I made my pitch.”

She also said she planned to meet with Arkansas Lt. Governor Bill Halter, who had been instrumental in finding a venue for the event.

Clinton responded that Olbermann was politicizing the clinic, and that it wasn’t helpful for Olbermann to do that. He said he did not feel he could show up now, because the event had turned political.

Eve said that Halter had been very helpful, and that the event was not political. She said that Halter’s intercession had been key in getting the Convention center to give the clinics space.

Clinton replied that the event was becoming political, and that it was clear what was happening: a primary of Blanche Lincoln.

Olbermann, who has invited his viewers to contribute to the National Association of Free Clinics in advance of the event, has said on his show that “I want Sens. (Blanche) Lincoln and (Mark) Pryor to see what health care poverty is really like in Little Rock.” Lincoln has met recently with Joe Biden and President Obama, but has yet to agree to vote for debate on health care to proceed in the Senate.

Earlier this week, Bill Halter appeared on Countdown, with guest host Lawrence O’Donnell, who asked if he was planning a primary challenge of Lincoln. Halter did not foreclose the option, but said he “didn’t want to focus on politics or my political future” at the expense of the free medical clinic event.

Halter served in the Clinton White House and was appointed to the Social Security Administration.

Clinton told Eve that Lincoln has done a great job as Chair of the Senate Agriculture Committee. He felt that the most important thing for Lincoln’s reelection, was for President Obama to be able to go into the State of the Union address with a “win” on health care behind him and to focus on jobs and the economy.

“I think he was saying that job growth is critical to the survival of endangered incumbents, and that blocking health care won’t put the wind at the backs of the administration, so they can get on to jobs and the economy. If we can get through health care, I think he was saying, then Blanche Lincoln’s political futures will improve. That’s what will get her re-elected,” said Eve.

In a statement provided to the Associated Press, Sen. Lincoln commented on the free clinic, saying that “this one-day clinic is a blessing, but it is not a sustainable way to deliver health care for the thousands of uninsured and underinsured Arkansans.”

Eve Gittelson will be covering the clinics this Saturday for FDL, which run from noon until 7 p.m. at the Statehouse Convention Center in Little Rock. Over 1,000 volunteers have signed up to help, and as many as 80 physicians will be on hand, according to Arkansas Matters.

Adenocarcinoma in PAP smear (photo: euthman via Flickr)

Days after a controversial recommendation from the US Preventive Services Task Force on breast cancer screening, a separate organization has recommended less screenings for cervical cancer. Anyone seeing eerie parallels or ready to scream about “rationing” needs to read a bit more closely:

New guidelines for cervical cancer screening say women should delay their first Pap test until age 21, and be screened less often than recommended in the past.

The advice, from the American College of Obstetricians and Gynecologists, is meant to decrease unnecessary testing and potentially harmful treatment, particularly in teenagers and young women. The group’s previous guidelines had recommended yearly testing for young women, starting within three years of their first sexual intercourse, but no later than age 21.

Arriving on the heels of hotly disputed guidelines calling for less use of mammography, the new recommendations might seem like part of a larger plan to slash cancer screening for women. But the timing was coincidental, said Dr. Cheryl B. Iglesia, the chairwoman of a panel in the obstetricians’ group that developed the Pap smear guidelines. The group updates its advice regularly based on new medical information, and Dr. Iglesia said the latest recommendations had been in the works for several years, “long before the Obama health plan came into existence.”

She called the timing crazy, uncanny and “an unfortunate perfect storm,” adding, “There’s no political agenda with regard to these recommendations.”

I would argue that there would be a political agenda if these recommendations were somehow muzzled until after the health care bill was dispensed with. The fact that they’re coming out at this sensitive moment would be the opposite of how any good plotter would act. In the case of the USPSTF, they operate independently of the Dept. of Health and Human Services and were stunned by the reaction to their report.

Further, the American College of Obstetricians and Gynecologists has absolutely no role in the health care bill whatsoever, and they don’t agree with the USPSTF recommendation on mammograms. . . .  They find that there are more potential pitfalls to overscreening on pap smears than on mammograms. In addition, the findings of either group are not binding on doctors or patients; as the Health and Human Services Secretary made abundantly clear the other day, even the USPSTF recommendations are little more than advisory – though I still maintain they may effect cost sharing gudelines.

Preliminary reports show that insurance companies will continue to pay for mammograms starting at age 40. They have little ability not to – the procedure is mandated at that age in 49 of the 50 states. Changing the guidelines would involve changing all those state laws. There has been no comment from insurers yet about the cervical cancer guidelines.

The POP art contest made today’s Washington Post:

[I]t was one thing for Fairey to turn an image of Barack Obama into the striking “Hope” poster — he’s a photogenic guy! — another thing to dramatize the argument for government-funded health insurance. You can vote for your favorite on the group’s Web site, though the winner will be picked by a panel of judges including Arianna Huffington, Margaret Cho and Jesse Dylan.

Well, I think the results are pretty awesome, but you be the judge.

Vote here for the winner of the POP art contest. Voting ends tonight at midnight.

Looks like even the Palinites are getting sick of the ‘Cuda this week. Amidst the BOOOOS one can hear “QUITTIN’ ON THE JOB!”

Stopped clocks, as they say.

Meanwhile, the ‘Cuda’s beloved Facebook page is getting bombarded with angry posts like this.

My family (wife, 3year old, and 10 year old) and I waited for 6 hours to get a book signed by Sarah Palin tonight. She left 300 folks standing in the rain and cold without explanation or even an address at exit. That is 1800 hours of voters lives sacrificed for nothing due to lack of concern by another politician for… our time, money and effort to see a cause through. She could have invested 45 minutes and not received the boos, or sign my book chants. I know that the majority of the folks that were chanting go Palin now are returning her books tomorrow morning. What a disappointment.

If this is the way the ‘Cuda manages a small-market bus tour, just think of what she’ll do for the country.

(h/t TS)

Suppose you lived in a country whose health care system had become so dysfunctional, wasteful and inhumane that almost everyone with any sense realized it required fundamental reform. Everyone conceded that it cost from 50 to 100 percent more per person than comparable countries, yet if was producing no better and often worse health outcomes. They knew it was gobbling up the federal budget and capturing its GDP at a frightening, unsustainable pace. In addition it left at least 47 million uninsured, millions more underinsured and still more fraudulently insured, forced millions into bankruptcy, while too often treating those it presumably “cared” for in an uncaring, negligent, even reckless and sometimes criminal manner. How would you fix it? Where would you even begin?

The first thing you might do is try to understand how you got into such an indefensible mess, and that’s partly what Maggie Mahar does in her superbly written and exhaustively documented book, Money-Driven Medicine: The Real Reason Health Care Costs So Much. But don’t expect a simple diagnosis or easy answers. It’s not a single “reason” but rather a complex history that has seen America’s health care system transformed by a corporate culture whose incentives are at war with basic values of good medicine.

In first tracing the last 50+ years of this devolution, Mahar describes how doctors gradually lost control of their profession to the corporate MBAs who arrogantly believed that hospital corporations could replicate Walmart. Many CEOs of for-profit hospitals became rich, driven by the need to grow and consolidate. But as they did, the biggest and worst of them — NME, Tenet, Columbia/HCA (Rick Scott), Health South — variously resorted to massive Medicare fraud, kickbacks, pervasive patient abuse and even kidnapping to fill their beds. Many executives should have gone to jail, but almost none, and no one at the top, ever did.

We often hear that “more care is not better care,” and Mahar traces the incentives that lead hospitals, doctors, device and drug makers to “do more” with insufficient attention to whether it actually improves patients or is worth the costs/risks. Contrary to market (and consumer-driven care) enthusiasts, the “supply” side too often drives demand: if hospitals are overbuilt with too many beds, it’s an incentive to prescribe more treatments, longer stays, do more tests and bring in more specialists.

Instead of solving the problem, competition makes it worse, as competing hospitals entice doctors — the doctors bring the patients — with lavish technology centers and technology “wars” — but the more MRIs you have, the more incentive there is to overprescribe their use, driving up costs but with no overall benefit to patients. And then there are the medical “mistakes,” so pervasive that one doctor observes, “Hospitals are dangerous places — especially if you do not need to be there.”

In a chapter on drug and medical device makers, Mahar anticipates the pre-reform price increases announced earlier this week. Big Pharma is not driven by increased demand so much as the need to meet Wall Street expectations, conditioned by years of spectacular profits powered in part by the Medicare drug bill of 2003. Their R&D budgets, which they claim to justify unrelenting price increases, are dwarfed by their marketing budgets and efforts, in which physician integrity becomes compromised by collusion and patients are convinced they must have the latest, more expensive drugs even though their efficacy and value remain unproven.

It’s an overwhelming, dismaying story –and I’ve touched only a tiny fraction — and through it all we read of physicians torn between the traditional ethics of their profession and the incentives and temptations of the money-driven system that surrounds them. Mahar shows the best of them struggling to create islands of ethical sanity, to collaborate and share information (using IT reforms, evidence-based medicine) in a hospital and drug industry that would rather withhold information because it’s “proprietary” or a “trade secret.” We see this system capture and corrupt everyone, including regulators during the last two administrations, even to the extent of censoring critical reports in medical journals.

Mahar summarizes the malevolent forces (178):

If you believe the Dartmouth research which says that one in three health care dollars is wasted, the conclusion is inescapable: the real reason Medicare appears to be headed for bankruptcy is not because the nation is graying, nor even simply because the cost of new technology is skyrocketing. The problem lies not in the cost of progress, but in the way we are using — and overusing — that technology in a money-driven system where device makers, drugmakers, some hospitals, and even some doctors all seem to be selling something — and selling it hard.

The obvious questions are: how do we fix this? Where do we begin? Is there some way to get back to a doctor-patient relationship based on trust, and is that enough? As Mahar notes,

The U.S. is in the only country in the developed world that has chosen to turn healthcare into a largely unregulated for-profit enterprise.

Healthcare is a necessity–like heat or light. This is why most governments regulate it, understanding that we can’t let patients be gouged.

Mahar finished Money-Driven Medicine in 2006, before the current debates on health reform, but she writes frequently on the current reform efforts at her blog, Health Beat. We’ll have a chance to ask how well the House and Senate bills address the problems of money-driven medicine.

So with that, please welcome Maggie Mahar. And as always, please keep comments respectful and questions relevant to the book’s topics.

But who's buyin'? (photo by Mike Quick)

The more I look at the merged Senate bill, the more I’m afraid that Harry Reid might have been laying the ground work to betray progressives on the issue of the public option, and gain the support of Olympia Snowe. Many of Snowe’s top demands managed to make their way into the bill.

Harry Reid decided to take the terrible “free rider” provision championed by Snowe from the Senate Finance committee bill instead of the employer mandate from the HELP bill. Reid went with a very much weaker individual mandate more in keeping with the wishes of Snowe. He also kept the terrible “nationwide plans” from the SFC bill. Snowe strongly backs the nationwide plans and claimed it was one of the reason she voted for the bill in committee.

Reid did not just go with the provisions from the SFC bill strongly favored by Snowe. He took the unusual step of even further watering down provisions that Snowe wanted changed. He dramatically reduced the minimum requirement for what qualifies as insurance. He reduced the actuarial value of bronze level plans to 60%. That is even lower than it was in either of the committee bills. The merged bill would also allow people up to the age of 29 to buy extremely low value catastrophic plans. The SFC bill would only let people 25 and younger buy these low value plans. Both changes were championed by Snowe.

The other issue of concern is the design of the public option’s opt-out provision. It does not seem well thought out. There is no restriction on when states can start opting out. At the very least there should have been a clause, so that people currently on the public option would get to remain on it, at minimum, until the next open enrollment period if their state opts out. Reid may not have put a lot of work into designing the opt out provision because he did not plan for it to remain.

Tom Carper has recently began working with Snowe to bring back a new, re-designed trigger. Reid is aware of these efforts. Even if Reid has not directly endorsed Carper’s plan, he doesn’t seem to be trying to put a stop to it either. Just today, Reid took the very strange step of taking reconciliation off the table.

It is possible I’m just being paranoid and reading too much into these changes. They may have nothing to do with Snowe. It could also be that Reid has made these changes in the hope of convincing her to at least not filibuster a bill with a public option. He might think that by giving her 90% of what she wants, she will be willing to accept the opt-out public option.

Either way, this is something I plan to keep a very close eye on. If progressives find out that Reid’s support of the public option was purely for show, while at the same time he secretly worked with Snowe to kill it with a trigger, that would not go over well with the base. Reid does have the power to get a public option passed, there is no good excuse for failure.

When nobody was really paying attention, Grayson began working to sign Democratic cosponsors to Ron Paul’s H.R. 1207, which authorizes the GAO to conduct a wide-ranging audit of the Fed — something that has never been done it its history. Thanks to his efforts, the bill has gone from 190 to 311 bipartisan cosponsors.

When a last-minute attempt by leadership and the banks threatened to derail the Paul-Grayson bill, Firedoglake circulated a letter signed by labor leaders, noted economists, authors and financial bloggers to demonstrate progressive support for the effort. The letter pulled no punches, asserting that the Fed had “extended massive secret bailouts to major financial institutions” and calling upon Democrats on the Financial Services Committee to stand up to the banks by supporting the Paul-Grayson bill.

Despite the vocal opposition of Chairman Barney Frank and the fierce lobbying on the part of the central bank itself, 15 Democrats bucked leadership and the measure passed. According to the Huffington Post, “Key to winning Democratic support was a letter posted early Thursday from labor leaders and progressive economists” which was “organized by the liberal blog Firedoglake…Grayson was able to show Democratic colleagues that the liberal base was behind them.” During the committee debate, Grayson quoted from the letter.

Firedoglake is proud to be a part of this historic moment, and of the role we played in supporting Rep. Grayson’s work by urging members of Congress from both parties to take an important step toward transparency in our financial system. Congratulations to the members of the Financial Services Committee for their remarkable achievement, and to Representatives Paul and Grayson for their hard work and leadership.

Wish you were here? (photo by Paul Keller)

Guantanamo Bay, Cuba, 11/18/09 – Legal proceedings, such as they are, rumbled to life again today at Guantanamo Bay. Pre-trial issues in the case of Mohammed Kamin, an Afghan man who was captured by the U.S. in Afghanistan in 2003, were heard in a military commission courtroom on a small hill a few miles away from where the more than 200 detainees left at Guantanamo are housed.

The proceedings were a non-event before they even took place, unattended by even a single journalist and unremarked upon by political elites, many of whom spent the week arguing about whether military commissions or federal courts were the appropriate venue for trying alleged terrorists.

Soon after the proceedings were gaveled to order, President Obama, speaking to FOX News in Beijing, said that the detention facility at Guantanamo would not close in January.

“I knew this was going to be hard,” the President said referring to an executive order he signed on January 22 ordering the detention facility to be shut within a year but “technical issues” as well as “politics” got in the way of closing the facility. He stated that he anticipates the facility will be closed at some point next year.

Many of the President’s political opponents have taken to the airwaves this week to laud the use of military commissions as the only sure-fire way to provide justice for those who are accused of terrorism.

Meanwhile back at the commission proceedings, it was business as usual – meaning that the judge spent more than two hours covering legal issues that have virtually no precedent in military commissions. But despite the hard work, it was hard to say that justice in Kamin’s case was any closer at hand.

Commission proceedings, since their inception, have been hampered by confusion about the rules, a lack of transparency, and other procedural hurdles. Today was no exception.

Trying a Man No One Has Heard Of

Mohammed Kamin is, in the words of his defense attorney, “someone who almost no one in the western world has ever heard of.”

When Attorney General Eric Holder announced on Friday that the five men charged with conspiring to plan the 9/11 attacks would be moved to federal court, there was no mention of what would be done with Kamin.

It was unclear how – if at all – a Department of Justice-led review of detainees held at Guantanamo might impact the case against Kamin. No one had bothered to tell his lawyer.

“The fact that we are standing here in this courtroom today suggests that we are going to proceed to military commissions,” Navy Lt. Cmdr. Richard Federico, the military attorney charged with defending the Afghan detainee, said uncertainly at the beginning of the proceedings today. “That would be my assumption too,” chipped in Judge Thomas Cumbie.

There is a making-it-up-as-we-go feel to these proceedings which is inevitable for a system of trials for which the Congress, courts and executive keep changing the rules. For example, there was discussion today of a new pre-trial hearing date in December in the Kamin case.

But officials said that the new rules for the military commission proceedings – which the Department of Defense needs to alter to conform with reforms passed by Congress on October 29 – have yet to be released by the Department of Defense. Officials with the Office of Military Commissions at Guantanamo acknowledged today that they have not even seen a draft set of the new rules.

Any rulings issued in connection with today’s hearing or in the court’s next hearing on this case (scheduled “on or around” December 16) may have to be re-litigated when the new rules are released, further delaying a date when the Kamin case might reach a verdict. Kamin has been held for more than six years without any meaningful judicial review.

Other problems unfolded as the hearing moved into its second hour.

Basic discovery information has yet to be passed on to the defense. For example, the defense told the court today that they still have yet to receive many of the accused’s statements.

The prosecution, more than 1.5 years into formal legal proceedings against Kamin, recently provided an interrogation log which shows that he has been interrogated 17 times, yet summaries and/or transcripts of what was said at those meetings have only been provided to the defense for four sessions. “This is elemental stuff,” Federico told the court.

Two Guys Not on Google

Captain Clay West, who acts as co-defense counsel, raised yet another thorny issue: two Afghan men who initially interrogated Kamin can not be found by the U.S. government for questioning. West suggested that these men, who were on the U.S. payroll, may have “softened up” Kamin and they ought to be questioned by investigators to determine what role any abuse may have played in subsequent statements.

Government prosecutors shot back that they were doing everything they could to find the two men. “Its not like we can put their names in Google,” said Air Force Captain Jeremy McKissack, a prosecutor. Judge Cumbie suggested that so much time had passed since Kamin was captured, “they might be dead.”

“The government has worked five years to charge this case,” West said. “The government should suffer for not trying this case sooner, not Mr. Kamin.”

There were other questions too. After all, as Federico explained, it was his “ethical responsibility” to pursue every avenue he can to defend his client.

Is material support for terrorism, the charge under which Kamin is to be tried, a charge that will stand up under appeal? Federico told the judge that, in his opinion, it probably would not – even the Attorney General’s office expressed similar doubts before the latest Military Commissions Act became law – and argued that he ought to be able to make his case to the “convening authority” who has the power to choose who to prosecute.

Providing “support” for terrorism, as opposed to actually committing terrorism, has not traditionally been considered a violation of the laws of war, Federico argued, and it would be a waste of resources to try a case that is likely to be overturned. The judge promised to consider the motion.

It didn’t stop there.

What should be done about a system that was designed – according to rule – to try “enemy combatants” when a new administration now calls detainees like Kamin “unprivileged belligerents?” Federico says this is not accounted for in the rules. Are changes necessary? Federico says that this alone is enough to dismiss the case.

And on and on. All of these issues have to be litigated. Memos have to be written. Motions filed. Hearings convened.

Almost every issue breaks new ground. Kamin elected not to attend this hearing. He has skipped every pretrial motion. The judge warned that there may come a time when it is necessary to “forcibly extract” him from his cell and make him attend hearings. But it is not clear when that time will come. Or who will decide. More memos. More unchartered territory.

This is the state of play with a military commission system that was put in place in 2006 and overhauled just a few weeks ago. New rules are being put in place while detainees are being tried. Changes are inevitable and as the clock continues to run, it becomes harder and harder to convene a trial that is seen to be timely and fair.

This is what it takes to build a legal record and develop a complex legal system. It’s fascinating for lawyers to watch. But it is not the way a sophisticated country should be managing justice.

There is another option.

Thankfully the federal judicial courts are already prepared to handle the most complex terrorism cases. Since 9/11 the federal system has reached a verdict on 195 cases, finding more than 90 percent of alleged terrorists guilty.

For those of us who have seen the Guantanamo system of military commissions operate, it is hard to believe that any politician would argue that what we have here is what we need. Especially when a system of justice, with a proven track record, stands by, ready to do the job.

Texas Republicans are truly an entirely separate category of stupid.

“For somebody like me who has put together the logistics of a court trial, you’ve got weak links all along the way from the jailers, the bailiffs, the clerks, the jurors, the judge, everybody in the courtroom, their families…You’ve got subways, tunnels, bridges all subject to terrorism.”

Then, in an apparent reference to the billions in federal cash that flowed to the city after the Sept. 11 attack, he added: “And unless they’re trying to create a new jobs bill by allowing terrorism back in New York then this is insane. And even that would be insane.“

And if anyone knows insane, it’s Gohmert.