Commentary from Dave Durenberger

March 14 , 2008

THIS IS NOT A BILL
Breathes there an American who knows what price is paid for her medical experience and by whom? For how many years have insured Americans lived with "This is Not a Bill" health insurance payment system? Along comes New York's new Attorney General, Andrew Cuomo, to tell us the system was designed by and for insurance companies. And it is run by one of them to benefit insurers who send the bill for the difference between what doctors and hospitals should be paid and what they bill, to each of us. So what's new? The AMA has been telling us that for years.

What's new is that Cuomo has more power than the AMA and he just used it to force health insurance plans to use and disclose quality benchmarks. What's new is that he informs us that the Health Insurance Association of America developed the "This is Not a Bill" which they call Prevailing Healthcare Charges System (PHCS). It was sold to one of its members, United Health Group before HIAA merged into America's Health Insurance Plans, the trade association for health plans of every kind in America.

What's not new is "reasonable and customary" or prevailing charges. They have been around since the old non-profit Blues used the term to describe what a community's physicians and hospitals were charging for a wide variety of medical goods and services. In 1965 the phrase was written into the Medicare law as the basis for reimbursement to bring the medical associations on board and assure them the government wasn't going to set prices. Blue intermediaries and carriers kept the "reasonable and customary" claims files and dutifully reported to Medicare. Many Blues then converted to for-profit companies and, along with other local insurance plans, followed the merger and acquisition course to national plans. Each had to find ways to determine what was reasonable and customary and thus the PHCCS.

What's not new is that doctors and hospitals who disliked the system learned to live with it. At least until the advent of "out of network providers" and Preferred Provider Organizations (PPO) came into vogue as a way for some providers to avoid the scrutiny that comes with reasonable, customary and efficient health service networks. That was followed by the consumer directed movement with high deductible plans and increased use of "out-of-network" docs.

So where are we? Congress decided in 2003 to enhance the market for high deductible indemnity insurance plans with greater tax subsidies for the premiums and the deductible (HSA). They also decided to spend whatever it takes to move the Medicare program out of HHS/CMS and into AHIP members, using Medicare money to provide a special preference for individually-owned fee-for-service indemnity insurance.

The money the insurance company cannot make from CMS, they make from restricting access to provider networks with whom they've negotiated prices. This leaves the consumer who wants an out-of-network doc or hospital to pay the bill that UnitedHealth's Ingenix and the PHCS comes up with. The New York Attorney General's office calls this shared insurance data base "garbage in, garbage out" claiming insurers sometimes keep data from high-charge providers out of the data base to lower the reimbursement and raise the amount the consumer must pay.

I have no idea where the truth lies. I know the work of Ingenix in other areas has been very good. I know that Richard Anderson believed the same when he was attracted out of the CEO position at NWA to run Ingenix – that is before a stronger force pulled him to run Delta Airlines and work on its acquisition of NWA. I suspect Cuomo will do a deal with the plans and UHG in which the Ingenix PHCS system is conveyed to some independent entity like an academic center.

MORE ON NATIONAL HEALTH INSURANCE plans and their popularity. Besides the hearings this week on the disadvantages of Medicare Advantage in both House committees of jurisdiction, a California poll of hospital executives reveals that 91% disapprove of the way UnitedHealth Group does business with them. This compares with Wellpoint's 48% against 20% favorable, Cigna's 47% to 44%, and Aetna in the best shape with 57% approval and 37% disapproval. Wall Street also reacted negatively to earning reports from some of the big plans.

Meanwhile, a study by Fidelity Investments showed that a 65 year old couple retiring this year without employer-paid health insurance, faces a total of $225,000 in out of pocket costs during their lives – compared with a 2002 estimate of $160,000.

MEDICAL PRODUCTIVITY
Nobel economists, and even some health economists, will tell you that the best way out of a recession is to increase productivity. We could start with America's $2 trillion healthcare industry which is the only part of the U.S. workforce that's been growing during the last few years. Why do we need all those people? We don't. We hire them because "medical productivity" is an oxymoron in American medicine. In fact, the MedPAC each year makes recommendations to Congress on increasing medical producer payments to reflect increases in the medical price index, minus "productivity." They use the BLS estimate of productivity improvement for all of the American economy because we don't know the word in the healthcare system.

Small Example: The colonoscopy is an examination of the lower intestine made possible by flexible probe technology. It is administered by a gastroenterologist, a profession which has grown with the technology available to do routine diagnostic colonoscopy as well as polyp or other surgery. Most clinical systems believe that internists and/or ancillary health professionals can be trained to do the diagnostic colonoscopy, but the American Gastroenterological Association has successfully lobbied "safety" issues to prevent that from happening. They recently forced Aetna to back down from its plan to stop paying for the use of PROPOFOL, a powerful anesthetic which provides quick and reliable patient sedation, but must be administered by an anesthesiologist at an extra cost of $300 to $1,000.

I am not covering the issue of how often and how extensive the diagnosis need be, and the AGA argument that people won't get needed diagnosis unless they can be assured it's a no pain/no discomfort/no time deal. I haven't researched how many diagnostic colonoscopies are performed every year. But you get the idea. I hope. You know what comes next? Athicon Endo-Surgery at J and J is seeking approval for a computer assisted sedation device to eliminate the anesthesiologist and MGI Pharma wants approval for Aquavan, a PROPOFOL variant which nurses can administer. Just like they can be trained to do the whole procedure!!!

QUALITY AND EFFICIENCY LEADER JOSEPH JURAN died March 1st. Born Christmas Eve of 1904 in Romania, Juran came to Minneapolis in 1912, graduated high school at 16, and became the University of Minnesota chess champion before graduating with a degree in electrical engineering. In 1951 his book "Quality Control Handbook" marked him as the master of this new industrial science. Along with Edmund Deming he made the most important and lasting contribution to the rebuilding of Japan. The work of "quality circles" of lean manufacturing and the theory of six sigma perfection were all attributable to Juran. In 1979 he started the Juran Institute as his consulting firm and the Juran Foundation which, in 1998, merged with the Carlson School of Management at his alma mater UMN. Today Jim Buckman runs this quality control center as the Juran Center for Leadership in Quality.

Those of us who have come to know both the Japanese and American medical systems assume neither Deming nor Juran were ever hospitalized in either country because there is so little evidence that what every other industry has learned has been transferred to hospital systems. The U.S. spends twice as much per capita as Japan on medical services and it shows in our inefficiencies and the Japanese generally poor performance. I know U.S. hospital leaders go to Japan to learn "Toyota lean" processes, but no one in Japan, except patients at Toyota's Hospital, know that the industrial processes which made Toyota the no. 1 auto producer in the world are nowhere applied in medicine.

JOHN SYMANITZ DIES AT 103
We know Garrison Keillor created Lake Wobegon from the little communities that were built on a few, small glacial lakes in Stearns County, MN, where I was born. Avon, MN is located on three Spunk Lakes, on one of which you can today see "Fisher's Nite Club" of which Garrison is a part-owner. John Symanitz was born in Avon in 1904 and died this past week at his home in Minneapolis at 103. John sold health insurance from the time it was invented and billed his last renewals at age 99. He was the most famous 4th Degree Knight of Columbus in Minnesota ever. He bought a new Buick every year, was the best dresser and the best polka dancer at any event.

A past President of every health underwriter or insurance association, he seized on every such opportunity to ask me, his Senator, to speak. I would always say, "What do they want me to speak about?" and John would say, "They want you tell them they will make more money. But you just tell them what they need to hear." John was widowed twice and took his now widow Estelle out for the first time on Valentine's Day in 1987. They married shortly, but only after he promised her "20 good years." She ended up with 21 and is a really happy person for each of them.

MORE ON MINNESOTA RETAIL HEALTH CLINICS
Following the trends here of hospital systems buying retail clinics, as well as physician group practices, solo hospital system North Memorial is planning eight urgi-care clinics and 22 retail clinics in the northwest metro area of MSP by 2010. They recently bought Now Care Medical Centers, Inc. from Bill Lenmark for an undisclosed price. North Memorial is a tax exempt, not-for-profit organization and may well disclose the purchase price if you ask. Lenmark's astute business talent built Now Mark into 300 employees, eight Now Express clinics in Cub Foods stores, and seven urgi care centers making $14 million a year.

HOOSIER HEALTHWISE is Indiana's Medicaid program and has the lowest income eligibility standards for non-disabled adults in the country. Starting January 1, Indianans aged 19 to 64 who earn less than 200% of the federal poverty level and who have been uninsured for 6 months, are eligible for The Healthy Indiana Plan (HIP) powered by POWER – a Personal Wellness Responsibility Account valued at $1,100 per person per year.

Contributions come from participants at 5% of gross family income ($0-$85 for individual and $0 to $105 for family of 4); up to 50% from employer withholding; and the balance from a state trust fund created with $129 million in new state cigarette taxes. Preventive benefits are free up to $500 and medical cost reimbursement kicks in at $1,101. The HIP is part of a larger and comprehensive state plan to improve access, costs and benefits which qualifies for federal matching funds thanks to a waiver. Also included is a tax credit for qualified employer wellness programs and for small employer Section 125 plans.

DOING IT THE OLD FASHIONED WAY can have its problems even among labor unions. Andy Stern has been enormously successful in building the strength of the SEIU since taking over as President of the International in 1996. He capped that success by walking out of the AFL-CIO in 2005 with six other large unions charting an independent course to restore their national political power. Stern does it, critics and admirers say, by centralizing power, appointing his friends for key positions, and demanding loyalty from locals and state affiliates. He also does it by making friends from some natural adversaries around common interest political or policy issues, as in health care reform.

I've found that he and his aides rarely miss a beat, leave a base uncovered, or seize an opportunity. They are always available, always interested in finding common ground, but tough as nails as negotiators. SEIU has had a great deal of success in lower-compensated health profession and semi-professionals and makes a lot of hospital c-suiters madder than hades. But, even at Catholic Health Association members, a unique target for union campaigns, they've earned grudging respect and some change of approach/policy.

Then along came the California Nurses Association to do battle in Ohio against the SEIU and its efforts to organize 8,300 employees at nine Catholic Healthcare Partners hospitals. So tough are the California Nurses they forced the SEIU to back off a planned certification election and now the battle is engaged. The hospital system had to get restraining orders to keep the nurses from invading restricted areas of Ohio hospitals. Wow, this must remind some of those Ohio patients of the good old days of John L. Lewis and the United Mine Workers. This growth of unionization among healthcare employees is a phenomenon to be watched closely, especially by those concerned about the need for greater productivity and efficiency and lower costs in healthcare services.

MY HOME MAY BE MY CASTLE, but my car is not my armor-plated humvee. Nor is anyone else's. Most health reformers have turned to health maintenance and accident prevention as inexpensive – and socially responsible – ways and means to reduce health care costs. Right. So let's get started. My productivity-guru friend Tor Dahl tells the story of a Norwegian named Kjell Uleberg who, on September 27, 2006, was arrested for drunk driving with a blood alcohol level of 0.7 which is legal in the U.S. He spent 30 days incarcerated, paid a $77,692 fine, and lost his driver's license for three years. 40% of U.S. highway fatalities are alcohol or drug related. If we had the same driving under the influence penalties as Norway, we would save 27,180 lives and multi-millions of dollars each year. Americans claim to have the right to health care and the right to resist the imposition of serious penalties for high risk behavior. We cannot have it both ways.

CONSUMER DRIVEN HEALTH CARE
The University of North Carolina Healthcare System is now asking patients at its affiliated hospitals and medical clinics to pay the insurance co-pays and the costs of tests in advance of receiving the services. They say that the increased use of high deductible health plans is driving up accounts receivable and the costs of collection. The new policy is designed to reduce letters, phone calls and other less friendly collection practices. UNC Health Care says no one will be denied care when needed and will be given the opportunity to qualify for the system's indigent care discounts, for Medicaid, or for no-interest payment plans.

WHAT WE CAN DO ABOUT THE HEALTH CARE CRISIS
Former Senate Majority leader Tom Daschle presented 300 people with his answers at the University of St. Thomas Opus College of Business on Wednesday evening. It was his first presentation of his new book of the same name outside Washington D.C. The former Democratic leader is an active national advocate of Barack Obama's candidacy for President and demonstrated a political expert's grasp of problem definition in ways that prompted something close to 299 questions from his audience. The health system folks in the audience heard his advocacy of many consensus policies to drive value in the industry. Then his rationale for a Federal Health Board to substitute for elected representatives in making the difficult choices that move a nation from status quo to value design, delivery and purchasing that in a pluralistic system government can't make.

©2008 Steve Sack, Star Tribune

WHAT AN ELECTION YEAR THIS IS
A year ago most pundits expected Hillary Clinton to be the Democratic candidate for President and John McCain the only likely Republican with a chance to defeat her. Six months ago McCain looked like he was knocked out and Clinton looked the same two weeks ago. Today McCain is the GOP candidate for President and Clinton is in a knock-down, drag-out battle likely to go for months before the Denver convention. "All Democrats are concerned that we could snatch defeat from the jaws of victory," said former Bill Clinton chief of staff, Leon Panetta, the day after Ohio-Texas. But the day Obama's "momentum" became a political reality for Clinton, that potential became the party's biggest concern. Those who know them are convinced the Clintons will go to any length to return to the power the White House represents. Red phones at night and NAFTA talks in Canada are just the start, thanks to the Democrats of Texas and Ohio.

THE FUTURE OF THE DEMOCRATIC PARTY is being shaped right before our eyes this winter and spring and it is a sight to behold. My friend John McCain, who cinched the GOP nomination last week, is a placeholder for what it means to be a 21st Century Republican. The 1995-2006 Republicans blew the chance to do it, just like President Bill Clinton blew it for national Democrats in the last eight years of the 20th century. When John Kerry asked McCain to run with him for vice president, and when McCain asks Joe Lieberman, as I predict he would love to, you know change is in the air. When Chris Dodd and Connecticut Democrats dump all over Joe as they did in his 2006 primary, and then Dodd endorses Barack Obama for President, you know change is in the air.

A year ago a Democratic House Sub-committee chair told me "We have no idea who these newly-elected Democrats are. Some of 'em sound like Republicans." So a readily identifiable 50% of Americans (including many who are unlikely to vote for him) are pulling for Barack Obama to maintain his "turn the page" and fulfill our hope for the future message despite the down and dirty "knee-capping" of the Clintons. First by Bill in South Carolina and then by Hillary in the March 4 primaries. As a participant in and close observer of campaign strategies developed since campaigns went TV, polling and national, I can attest to the effectiveness of "you sling enough mud at the right time and the right wall and enough will stick to win." "Good guys finish last." No one can carry that message better than the smartest, most experienced, most ambitious person in national politics today, Hillary Clinton.

She is in fact both more liberal and more polarizing than Bill and more experienced at every facet of politics, policy and power than Obama. But if you believe that America is ready for a Democrat who believes what many Republican Presidents before him believe about this country and the presidency, you will be on the edge of your seat every day until August and Denver. Then the call will go out to Al Gore and to a handful of the party's more respected leaders to make the personal decision as to whether the Democratic Party is ready for the future or a creature of its past - and ours.

©2008 Steve Sack, Star Tribune

REPUBLICAN PRESIDENTIAL STRATEGY
The campaign against Hillary Clinton has been "in the can" as they say for a long time, regardless of which Republican ran against her. The fact that Barack Obama could be the likely Democratic candidate means the GOP strategy is evolving. Obviously the "experience" campaign by Clinton is not working and won't do much better for McCain unless we open a third new war front this year. The new campaign we call "the woodpecker on the tree trunk" approach. Or you just keep throwing mud at the wall hoping enough of it sticks to slow or stop momentum. This tactic works particularly well for McCain because he is pretty well insulated against anyone doing the same to him, as the recent New York Times character attack demonstrated. The young and the independents who favor Obama aren't customers for that product so I'd bet on a third strategy - whatever that might be.

WHY THE HEAVY PRIMARY ELECTION TURNOUT
Mitt Romney had it best with his insistence on changing the way Washington works. Here is an example from last week's House sub-committee hearing on corporate executive compensation from the New York Times: "The questioning mainly fell along party lines, with Republicans apologizing for bringing distinguished corporate officials [two fired executives and Mozillo from Countrywide] before the panel, and Democrats questioning everything from the income gap in America to the particular bonuses, stock sales and compensation the executives were awarded."

Only a few of our representatives have suggested that the real villains (or distinguished officials) in this recession are corporate directors who design and approve these deals while running or governing other corporations which enrich them, spouses, and families.

IT'S THE CAMPAIGNS, STUPID
Not the State parties. Let's hear it for the National Democratic Party for denying Michigan and Florida its national convention delegates and for the Democratic parties in Ohio, Texas, VT, RI, PA for not moving up to "super anything." Giving a broader swath of the electorate a chance to participate in the election selection process. John McCain is the GOP candidate already because Giuliani, Thompson, and Romney quit on us, not because he necessarily reflected what currently represents Republican values across the country. The lifeblood of election campaigns is not just money, although that sure helps. It is a candidate with a consistent appeal to voters who can also get them out to vote and to contribute. That's the lesson of Clinton-Obama. Governor Mike Huckabee got it. He stuck in to the end. So did Ron Paul who quit only to save his contested seat in TX. They both would have benefited, as would we, from the other "big names" not being quitters.

CONGRESS DEBATES FEDERAL BUDGET
Since 1974 the Congress has tried various institutional arrangements to enforce some fiscal discipline on itself and the executive. That was the year of growing concern about budget deficit impacts on inflation and the economy. New President Ford, a product of the Congress, was about to launch his "Whip Inflation Now" (WIN) crusade. Republicans held the Presidency and Democrats the Congress. A law enacted that year gave power to new Budget Committees in each House to enforce discipline with a series of Budget Resolutions on spending and revenue to which all other committees were required to conform. The 35th such effort starts this week with little evidence it's more than a pro forma process.

That's because the Democratic efforts to preserve and enhance entitlement programs, especially Medicare and Medicaid, are in irresolvable conflict with Republican commitments to reduce taxes. Complicating this year's effort is the Bush Wars and the executive's commitment to long term increases in spending on national security. Add to that the economic uncertainties we face as a nation making 5 and 10 year projections well nigh impossible and you have a classic exercise in fiscal futility. You and I are focusing on next year and beyond. Why would anyone want to be president? We are likely to get some idea about the answer to that. For the first time in many memories we have three members of the U.S. Senate fighting to take on the problems they couldn't find ways to resolve in the Congress.

LARRY CRAIG, DON'T QUIT YET
A Minneapolis jury last week acquitted a 39-year old Minneapolis man who was caught in the same summer sting operation at MSP airport that caught Idaho Senator Larry Craig. Vince Tuzon told the jury he couldn't be guilty of interfering with the undercover agent's privacy because the agent had invited a response with his foot-tapping. Craig has been unable to withdraw his plea to disorderly conduct, after prosecutors dropped invasion of privacy charges, and the case is before the Minnesota Court of Appeals.

SENATOR TIM JOHNSON OF SOUTH DAKOTA
The Democratic Senator, who is about 85% recovered from a life-threatening brain hemorrhage he suffered a year ago, and still uses mobility assist devices to get around, received the news that the only South Dakota Republican threat to him, millionaire businessman and former Lt. Governor Steve Kirby, announced he would not be a candidate.

SENATOR HOWARD M. METZENBAUM (D-OH)
For much of my three term career in the Senate, Howard Metzenbaum officed across the Richard Russell Building first floor hall from me. He died at age 90 this week. We spent a lot of time together, including years spent with his wife Shirley and others in a one-hour Torah study group in Arlen Specter's office. Our conversations were about many things other than legislation, but on those issues he worked hard to pull me to "the middle ground". Usually without success because he was an inveterate liberal. When he and I left the Senate at the end of 1994, his place as "the liberal" champion of the poor and middle class was taken by my colleague Paul Wellstone.

Howard used his seat on the Judiciary Committee especially to work to move Republican judicial nominees to "the middle" as well. Usually without success, as the case of Clarence Thomas illustrates. In that now-famous case, Metzenbaum went to extremes. It was his staff which worked the phones to find cause to undermine Thomas and they did, with Anita Hill. This was also a case, not often seen in the Senate, in which a moderate Republican, John Danforth of Missouri, went to the unusual extreme of working the Senate and the public on Judge Thomas' behalf.

On the floor of the Senate, Metzenbaum, like Wellstone, became the predictable thorn in the side of both Republican and Democratic leadership. He saw it as his responsibility to keep legislation which had not been reviewed by Senators and which leadership wanted to move quickly at the end of a session or before a holiday, from becoming law without some consideration. So those of us with last-day amendments had to get in line with Howard to be sure he was well informed on our cause and our solution. Wellstone accomplished the same thing without the last-minute line-ups, simply by filibustering any last-minute amendment or bill until his simple threat to do so caused the leadership to preview their needs.

TIGHTEN YOUR BELT
Everyone but our President is now acknowledging that we are in a national recession. Those who were the early believers now predict it to be deeper and longer than those with the "band-aid" stimuli expect. The reasons are many. It has been coming on for a long time. It will be a more significant policy challenge to the next President than the wars in the Middle East and south Asia.

Here's why: Prices and public spending are up consistently and across the board. Income, savings, and equity have dropped significantly. If there is a general cause, it is probably the laissez faire approach to governance in both the private and public sector which has so far characterized the 21st century. We didn't need restaurants to tell us they can't stay in business without changing menus and reducing portions to know food prices are out of our reach and getting worse. Watch Americans start plowing up backyards this spring to put in "war gardens" like parents did in the forties. Add fuel, healthcare and health insurance, home lending, state and local taxes, etc.

But savings, like winter temperatures in Minnesota, are at or below zero, along with home equity, income, employment and the U.S. dollar. Spending is up on CEO and Board compensation, government employees, and bail-outs, wars, interest on the deficit, the alternative minimum tax, earmarks, etc. Oh, and also on campaign spending and lobbying. In Minnesota, our Governor and potential GOP V-P candidate has recommended cutting taxes and postponing spending into the next biennium.

WIND AND WHEAT
Wobegoners are in an economic recession, facing a $ 7 billion tax increase from their legislature, and are unable to sell their homes to pay off debt. But out in "Greater Minnesota" folks in the real Lake Wobegon are sitting pretty. The hottest commodity market in the nation – the Minneapolis Grain Exchange – is telling us the demand for our wheat far exceeds the supply and our prices are going nowhere but up, up and away. $20 a bushel grain is triple the last record high in 1996. And corn prices are off the charts as well.

And out in those wheat, soybean and corn fields across the road feeding the ethanol plants, are the wind farms – a multi-billion dollar industry growing right out of the grain fields and showering us with unbelievable prosperity. No one believes it is all going to last, but it does mean something about the flat world, the need for energy and environmental policies, and the need to eliminate tariffs and subsidies to make that flat world fairer to rich and poor alike.

HOUSING POLICY
In television and radio commercial advertising, the National Association of Realtors informs us that, on average, the equity value of American homes doubles every 10 years. That means that realtor commissions as a percentage of sales prices double on average, as do all the other transaction fees which are percentage loaded on either sale price or mortgage loan price on these uniquely American "savings accounts." High-end homes, suburban homes, southern/western homes appreciate faster than northern, rural, low-end, inner city homes. But they all receive the same value-related tax subsidy from our federal government.

In fact the higher income "savers" with the higher-income homes and the faster appreciation receive much larger tax subsidies than the rest of us in the form of real estate tax and mortgage interest deductions from our income tax liability. And, for the growing number of Americans priced out of home ownership by this inflationary policy, we have created federal income-related home ownership subsidies which used to be really good where much of the "subsidy benefit" went to the builder.

So, a question raised by the way in which housing finance policy has driven down the value of homes in the last 6 to 9 months, is whether it is still necessary in a country like ours to subsidize home ownership the way we do. And whether it is still good policy to subsidize home ownership when we don't subsidize renters – many of whom are inner-urban dwellers, younger, older and fixed income or poorer.

HOPE FOR AFRICA
Larry Devlin was the CIA station chief in Kinshasa, the capital of the Democratic Republic of the Congo (DRC), at the time of independence from Belgium in 1960-61. The DRC is the third largest, and perhaps richest, country in Africa after Sudan and Nigeria. In his recent book, Devlin credits himself with saving the DRC from the Soviet Union. He also says he refused to execute an order from John Foster Dulles, which came with the poison to do it, to kill Patrice Lumumba because he was cozy with the Soviets. A U.S. supported Congolese by the name of Mobutu became President and served 35 years as one of the most powerful – and increasingly wealthy – dictators in Africa until overthrown by Laurent Kabila in 2002.

A few weeks ago at the University of St. Thomas, we hosted a new leader of the Congo who served as Vice President of the DRC from 2002-06. Azarias Ruberwa wasn't born when Larry Devlin ran Congolese politics. He is a 43 year old lawyer who ran for President in the first constitutional election for President in the DRC, and lost to Laurent Kabila's son, Joseph Kabila, who has been President since his father died. Ruberwa leads a national political party, runs an orphanage with his wife Chantal, and has organized the DR Congo National Prayer Breakfast for the last several years.

Lake Tanganyika Credit: Andrew Cohen

THE DEMOCRATIC REPUBLIC OF THE CONGO is a paradox. Life expectancy is low and poverty high. Literacy is low and contagious diseases high. Understanding of good governance is low and candidates for governance high. National revenue is low and national debt is high. On the other hand, the DRC has the largest reserves of precious minerals (like diamonds, gold, cobalt and copper), generous reserves of gas and oil in both east and west, and an over-abundance of hydro-power. It has no deserts but rich agricultural land and three harvest seasons a year. It has the second longest river in the world and the second largest forest (it produces 17% of the earth's supply of oxygen free to the rest of us carbon-producers). Lake Tanganyika rivals the world's "great lakes".

The current national budget of DRC is $3 billion and 25% of the revenue comes from outside the country. Sub-national governments are cutting deals with foreign powers to sell off mineral reserves without any understanding of the value of what is being sold and with almost none of the revenue going to the 60 million people of DRC. China, specifically, is trading infrastructure construction - especially badly needed highways - for controlling interests in mining companies and mineral-bearing lands. While the World Bank, the International Monetary Fund (IMF) and other nations lend money to DRC with conditions such as reduce debt, reduce human rights abuse, reduce corruption, slow down HIV AIDS (1/3 for abstinence e.g) the Chinese have no such controls on their loans and so the governments prefer doing business with China and there goes accountability. The rule of law does not exist in the country even though courts do and thus laws of private property, intellectual property, contracts, anti-trust and the like are unenforceable.

KENYA AND ZIMBABWE
Kofi Annan helped President Mwai Kibaki and the opposition candidate Raila Odinga come to terms with their pride, with their political allies, and with the future of Kenya. Let's hope the deal for a new constitution and a division of power and accountability holds up as well as it has in some other countries – Burundi comes to mind where a President cut a deal to relinquish his office in a transition that brought peace and at least the prospect of prosperity. Annan did the work, but Secretary of State Condoleeza Rice deserves as much credit as anyone. She's too busy right now to accept it. Kenya was critical. Vice President Cheney gets credit for asking the former Dictator Moi to step down. Kibaki is no Moi, but cutting a deal with the opposition was critical to fulfilling the many promises he made to Kenyans to restore accountability to government, not just free education, when he was first elected.

Robert Mugabe is another "president for life" figure in Zimbabwe who is being challenged by a strong member of his own Zimbabwe African National Union – Patriotic Front (ZANU-PF) party for election as President. Simba Makowi is widely respected and Mugabe is pulling out every trick to beat him and the Movement for Democratic Change (MDC) Party's respectable Mongan Tsuangini. And Cameroon is another country in which a 25-year presidency should be coming to an end, but for the stubbornness of President Paul Biya who insists on changing the 12-year old Constitution to allow himself a third seven-year term as President.

"WE BROKE IT AND WE NEED TO FIX IT"
A Minnesota National Guard member who has spent time leading troops in Iraq nicely sums up the future of U.S. national security policy. President Bush says we must remain in Iraq and Afghanistan until we are successful. John McCain tells us to stop debating whether we should have started a war in Iraq and learn how to finish it. Democratic candidates are vaguer. I think the "boots on the ground guy" has it right. As a candidate for the Presidency, Governor Bush foreswore "nation building." His middle east/central and south Asia policies have made it a necessity. Once the U.S. troops are on the ground we have broken Colin Powell's china, and we can't leave without picking up the pieces.

The problem is we just aren't equipped to do it.

NEVER ADMIT YOU ARE WRONG
When a Governor engages in prostitution, he is forced to admit wrong and to resign. When a President fabricates evidence to take his nation to war, he is not. Nor is it a lie. It isn't anything but an after the fact "failure to find evidence" as the Department of Defense's Institute for Defense Analyses determined this week. Quoting the report: "There was no operational connection between the Saddam Hussein government and Al Qaeda before the war in Iraq." That is a lot like "I did not have sex with that woman Ms. Lewinsky."

Does it bother you as it does me to know that more than a million Chaldean Christians have been forced to leave Iraq since the war started and that the outspoken Catholic Archbishop Paulos Faraj Rahlo, who refused to leave, was found murdered in Mosul this week?

100 YEARS IN IRAQ
Thanks to our friend John McCain for clarifying his comments about the length of time he believes the war in Iraq will require our military presence. His policy now reads: The United States of America should expect to have to keep "boots on the ground" and "planes/drones in the air" and/or "ships in ports" in Iraq as we have in Kuwait, Korea, Kosovo, Japan, Germany, and a current list of about 60 other sovereign nations for a long, long time.

This is more than a McCain policy. It certainly accounts for the derisive comments President Bush made about Barack Obama's suggestion he would consider speaking with current Presidents of Cuba and Iran if necessary. Said Bush: "The decisions of the U.S. President to have discussions with certain international figures can be extremely counterproductive. It can send chilling signals and messages to our allies. It can send confusion about our foreign policy. It discourages reformers inside their own country. And, in my judgment, it would be a mistake." Tell that to Ronald Reagan who went out of his way, and around similar advice, to tell Gorbachev and his predecessors why and on what terms he could expect to restore relations.

SUCCESS IN WAR
As the world approaches the 5th anniversary of the start of the U.S. war in Iraq, and as Republican Presidential candidate Senator John McCain suggests our military presence in Iraq "for 100 years," the President declares "My sole criteria [for reducing U.S. troops in Iraq below 140,000] is whatever we do it ought to be in the context of success." Once there was no Saddam and no WMDs, this President has been unable and unwilling to define success in Iraq. Recent public opinion polls suggest that reduced numbers of American deaths may be at least "context" for success. The hold put on further scheduled troop draw-downs means reduced body counts aren't success.

NESTLE will invest $19.6 million in a Swiss chocolate research center to meet the growing demand for premium and luxury confections.

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