know it's the Twenty-first Century, and the World Is Flat, and
9/11 Changed Everything. But when I look at the big issues facing the nation—rising health care costs and declining coverage; stagnant wages and growing income inequality; war and instability in the Middle East; our dangerous overreliance on oil—what I see is not the dawn of a new day but Groundhog Day. These issues are pretty much the same ones that dominated the headlines when I got into the journalism business a quarter century ago.
The enduring nature of our problems could mean three things. It could mean that the problems themselves are irresolvable, though I'd hate to think—in fact generally don't think—that's true. Or it could mean that old ways of thinking have failed and we need an entirely fresh approach, a new paradigm—though I have not come across any persuasive new paradigms lately.
Or there is a third option: that our public officials are not complete idiots, that over the years many of them have given a great deal of thought to these problems, and that they have fashioned promising solutions that are sitting in the government's toolbox waiting to be fully deployed.
Consider the dilemma of rising health care costs. When this issue was heating up twenty years ago, the Democratic Congress and the first Bush administration created the Agency for Health Care Policy and Research (AHCPR). The agency's mandate was to look at existing clinical studies and (it was hoped) fund new ones to determine which medicines, devices, and treatments work best and which are a waste of money. AHCPR was then supposed to use this knowledge to advise Medicare about what to pay for and what not to. Had the agency been allowed to do its job, the nation might now be spending countless billions less on health care. But as Shannon Brownlee explains this month (see "Newtered," page 27), antigovernment ideologues in the Gingrich House, egged on by health care industry lobbyists, managed to get much of AHCPR's funding and authority stripped out. Today, probably the single best way to lower health care costs and improve quality would be to create a beefed-up version of AHCPR. And indeed, Hillary Clinton, Barack Obama, and John Edwards have all announced plans to do just that.
Or take the issue of the uninsured. As Phil Longman argues elsewhere in this issue (see "Best Care Everywhere," page 21), we already have an ad hoc system that serves those who lack coverage: local public and charitable hospitals and clinics. Though woefully underfunded, these institutions, Longman demonstrates, provide surprisingly good care. What's needed, he says, is to rope them together into a loose but effective national network. And, it turns out, the federal government already runs a national system that can serve as a model—one that delivers, according to numerous studies, excellent health care at a relatively low price: the VA.
Then there's the mess in Iraq. General David Petraeus is now pursuing a counterinsurgency strategy that was lifted from books sitting on war college library shelves written years ago by warrior-scholars who served in Vietnam. Petraeus's counterinsurgency strategy may be too little, too late, and he may be peddling faulty intelligence (see "The Myth of AQI," page 34). But there's general agreement that we'd be in much better shape today if we'd pursued a serious counterinsurgency strategy early in the conflict. And if there is any hope of getting out of Iraq without leaving genocide and regional war in our wake, it probably involves using international negotiating strategies that were successfully field-tested by U.S. and UN diplomats in places like Bosnia and East Timor.
I don't mean to suggest that every warmed-over policy idea from the past is worth resurrecting, or that fresh thinking isn't needed. Longman's proposal for a civilian VA for the uninsured, though based on existing institutions, counts, I think, as a truly novel idea. The point is that because most of our big problems are of long duration, it shouldn't be a surprise that most of the solutions have been around a while, too.
This poses a political dilemma. In his new book The Argument, Matt Bai tells the story of the outside-the-Beltway liberal activists—bloggers, MoveOn members, billionaire funders—who in the last few years have been challenging establishment Democrats to stiffen their spine and win back power. As part of that effort, the activists have been trying to come up on their own with a fresh vision and dramatic new agenda for Democrats to run on. But the book ends with the activists—and the author—frustrated at their inability to do so. "Maybe that should tell us something," writes Kevin Drum in his review of Bai's book (see "What's the Big Idea?," page 43).
What it should tell us is that our hunger for bold new ideas may be leading us astray. What we really should be looking for are leaders with the knowledge and wisdom to select, from a vast cabinet of potential tools, precisely the right ones, and the political skills and determination to actually get the job done. That might not sound like the most inspiring of challenges. But it may be what the times demand.