Outcomes-based financing: Possibility and promise in global health


Outcomes-based financing: Possibility and promise in global health



Historical Present

The New Republic’s recent special issue, “Iraq: Were We Wrong?” underscores the reality that thoughtful and well-intentioned people can disagree about whether we should have gone to war. But if the moral calculus of the war remains complex and quite reasonably subject to argument, the fact that it has been a political disaster for George W. Bush now appears to be beyond debate. Which, in turn, begs consideration of a bit of counterfactual history: If Bush had not invaded Iraq, can anyone seriously doubt that he would be cruising to an easy reelection and in a position to deliver on his quite ambitious domestic agenda?

Bush’s decision to go to war may or may not have been wise, but it was certainly not inevitable. Imagine, for a moment, that the United States had used the outpouring of international support following 9/11 to strengthen the fraying sanctions regime on Iraq. At least in the short term, Saddam Hussein could have been contained and deterred as the U.S. pursued a more focused and widely embraced war against Al Qaeda and other terrorist groups around the world.

Consider the very different political landscape that Bush would likely be facing now had he opted for such a strategy. For one thing, his post-9/11 jump in presidential stature and bipartisan appeal would have left some lasting mark on his political standing, not the evanescent mark it now appears to have been. Americans would likely feel much better about the direction of their country than they do now and the rest of the world would have a more sympathetic and benign view of America. As a result, the domestic market for political change would be greatly reduced.

After the 9/11 attacks, Bush had an opportunity to lead a campaign against terrorism that would have been characterized by consensus rather than conflict, and would have been bipartisan rather than partisan. There is every reason to believe that a majority of Americans would have continued to support him had he pursued this more modest course. Consider the polling numbers. Two days after 9/11, Bush enjoyed an 84 percent approval rating, according to CBS News. It’s not surprising, of course, that those ratings were so high. But seven months later, having successfully toppled the Taliban, Bush’s approval rating had fallen just seven points, to 77 percent. By last month, in the same poll it had fallen to 44 percent. Which means that the first phase of Bush’s post-9/11 strategy cost him just seven points of support, whereas his second phase–invading Iraq–has cost him 33 points. Obviously, Bush’s approval ratings would not have remained at such stratospheric heights forever. But it is difficult to imagine that they would have fallen this far, this fast, in the absence of a major catastrophe, which is what Iraq has become.

Had Bush confined himself to a conservative domestic agenda, liberal Democrats would still dislike him. But absent the war and its aftermath, the extraordinary energy that has united all wings of the party against Bush would almost certainly not have developed. John Kerry (assuming he still would have been the nominee in the absence of war) would have been left with little basis for charting an alternative foreign policy or capitalizing on his Vietnam experience. Indeed, besides perhaps quibbling with Bush’s implementation of homeland security measures, he probably would have had to endorse Bush’s foreign policy and response to 9/11. His only other options would have been to run to the far left by opposing Bush’s invasion of Afghanistan (certain to doom his election chances) or to run to Bush’s right by advocating an invasion of Iraq (unlikely that he would have been able to unite Democrats around that platform). He would have been forced to focus exclusively on the economy at a time of economic recovery and domestic initiatives in the face of crushing budget deficits. Not the makings of a powerful challenge to an incumbent president.

It’s true that Bush has proven to be a high-stakes gambler on domestic policy as well as on foreign policy. But while his major gamble on fiscal policy–a series of large tax cuts combined with huge increases in spending–puts our nation in an extremely vulnerable position as we begin to cope with the escalating pension and health care costs of the retiring baby-boom generation, it probably wouldn’t have hurt him politically in this election cycle. After all, the tax cuts, along with the Fed’s accommodating monetary policy, are responsible for nudging a sluggish economy into an election-year recovery. If the past is any guide, this short-term rebound may well have been sufficient for voters to overlook the loss of jobs, meager wage gains, and escalating health care costs during Bush’s entire first term. Absent the war in Iraq and its spillover effects on the public psyche, Bush could have spun the 2004 expansion into an electoral advantage. But now the economy is overshadowed by Iraq.

Counterfactual history, of course, is speculation, and nothing more. There are, at any given moment, an infinite number of paths that history can take. So it’s entirely possible that not invading Iraq would have provoked some other unforeseen consequence that would have doomed Bush’s presidency. Perhaps Al Qaeda would have been emboldened by our failure to attack another country after Afghanistan and struck again inside the United States. Possible–but not likely. Assuming no further terrorist attacks, our domestic politics today would almost certainly be much more favorable to the president’s reelection had he elected not to fight a second post-9/11 war. Which is why if Bush fails to win another term, he will have only himself and his high-wire act on Iraq to blame.