The Pasty Little Putz, Dowd, Friedman and Bruni

In “Obama’s Artful Anguish” The Pasty Little Putz says on national security, the president wrestles with his own record.  MoDo has a question:  “Can 44 Subtract 43 From the Equation?”  She says President Obama is running away from W.’s legacy, and so is W.  The Moustache of Wisdom ponders “Obamacare’s Other Surprise” and says start-ups to manage mountains of health care information are transforming an industry.  Mr. Bruni, in “The Gift of Siblings,” says for those of us who have them, they color our characters and shade our lives as much as anything or anyone else.  Here’s The Putz:

President Obama’s speech on national security last week was a dense thicket of self-justifying argument, but its central message was perfectly clear: Please don’t worry, liberals. I’m not George W. Bush.

You can see why his supporters might be getting nervous on that front. The continuities between Obama and Bush on national security have always been there for those with eyes to see, but much more attention has been paid to them of late — to the expansive drone campaign that has targeted American citizens for execution without trial, to an anti-leaks campaign that has flirted with criminalizing investigative reporting, and to the perpetual postponement of supposed administration priorities like shuttering the prison at Guantánamo.

Against this backdrop, the president’s rhetoric last week was calculated to reassure and soothe. The promises he made in 2008, when he campaigned as a critic of wartime overreach, were revived, reasserted, amplified. He would push anew to close Gitmo … phase out indefinite detention … put limits on drone strikes … safeguard a free press … even wind down the war on terror.

But of course the year is no longer 2008, and Obama has been “the decider” for more than four years now. Which meant that his address had an air of self-critique that’s rare in presidential rhetoric. In the words of Esquire’s Tom Junod, one of the most perceptive writers on Obama’s drone policy, the speech didn’t just “speak to Americans in the language of moral struggle.” It tried to make the president himself “representative of moral struggle,” by turning “personal, almost confessional, in its weighing of doubt and its admission of second thoughts.”

This willingness to grapple with moral complexity has always been one of the things that Obama’s admirers love about him, and even liberals who feel disappointed with his national security record still seem grateful for the change from George W. Bush. If we have to have an imperial president, their attitude seems to be, better to have one who shows some “anguish over the difficult trade-offs that perpetual war poses to a free society” (as The New Yorker’s Jane Mayer put it on Friday), rather than falling back on “the secrecy and winking smugness of the past.”

I am not particularly nostalgic for the Bush era either. But Obama’s Reinhold Niebuhr act comes with potential costs of its own. While the last president exuded a cowboyish certainty, this president is constantly examining his conscience in public — but if their policies are basically the same, the latter is no less of a performance. And there are ways in which it may be a more fundamentally dishonest one, because it perpetually promises harmonies that can’t be achieved and policy shifts that won’t actually be delivered.

That’s a cynical reading on Obama’s speech, but it feels like the right one. Listened to or skimmed, the address seemed to promise real limits on presidential power, a real horizon for the war on terror. But when parsed carefully, it’s not clear how much practical effect its promises will have.

For instance, the president insisted that “history will cast a harsh judgment” on indefinite detention — but proposed no actual plan to deal with Gitmo detainees who (in his own words) “we know have participated in dangerous plots or attacks but who cannot be prosecuted.” He promised that drone attacks would be carried out only amid “near-certainty that no civilians will be killed or injured” — but also suggested, in defiance of much evidence, that this standard is already being met. He pledged to support efforts to “ultimately repeal” the post-9/11 authorization for the use of military force — but offered no timetable to contradict the recent testimony from a Defense Department official projecting another 10 to 20 years of military activity.

Over all, as the Brookings Institution’s Benjamin Wittes put it, the speech seemed written to align Obama “as publicly as possible with the critics of the positions his administration is taking without undermining his administration’s operational flexibility in actual fact.”

There are obviously good reasons to preserve this flexibility. The problem is that by making it sound as if American policy is about to change more than it actually will, the president’s rhetoric risks coming across as a bait and switch — on his supporters at home, but more important, on audiences across the Muslim world.

There, this White House’s foreign policy, in many ways reasonably successful, has met with its biggest disappointments. Far from abating, anti-Americanism has hardened in many Muslim countries, which presumably reflects disillusionment with the gap between candidate Obama’s promises and President Obama’s policies.

There is no good reason to overpromise yet again. Where the United States can step back from a wartime footing, we absolutely should. But where we don’t actually intend to, we should be forthright about it — rather than pretending that change is perpetually just around the corner, and behaving as though our choices are justified by how much anguish we express while making them.

Next up we have MoDo, writing from Dallas:

Do we dare to hope that the Bush administration is finally at an end?

After four years of bending the Constitution, the constitutional law professor now in the White House is trying to unloose the Gordian knot of W.’s martial and moral overreaches after 9/11.

Safely re-elected, President Obama at long last spoke bluntly about the Faustian deals struck by his predecessor, some of them cravenly continued by his own administration.

In a speech at the National Defense University, Obama talked about how we “compromised our basic values,” and he concluded with a slap at W.: “Our victory against terrorism won’t be measured in a surrender ceremony at a battleship or a statue being pulled to the ground.”

On the eve of the president’s speech, I was at the George W. Bush Presidential Library and Museum here, watching the film of Saddam’s statue being pulled to the ground.

It’s remarkable that Obama is trying to escape the shadow of the Bush presidency just as W. is trying to escape the shadow of the Bush presidency. Browsing the library, you wonder if these two presidents are complete opposites after all, as you see how history was shaped by an arrogant, press-averse, father-fixated, history-obsessed, strangely introverted chief executive.

Robert Draper, the author of “Dead Certain: The Presidency of George W. Bush,” perused the library with me and observed: “So 43 grew up entitled but could display a commoner’s touch, while 44 grew up hardscrabble yet developed this imperial mien. The former is defined by incuriosity, the latter by self-absorption. One is a late-blooming artist, the other a precocious writer. They can each make you kind of miss the other.”

Obama’s compelling speech on Thursday was his way of saying he didn’t want the seductive but morally dicey drone program he inherited from W. to define his own presidency. The way it had been going, one of the killer robots, hanging from the ceiling, might have made a fitting centerpiece for an Obama library.

W.’s library highlights his role in launching the Global War on Terror, an Orwellian phrase designed to conflate the sins of Osama, who was responsible for 9/11, and the sins of Saddam, who was not. That was the fatal mistake and hallmark of the Bush era. W., Dick Cheney and Donald Rumsfeld declared war on a tactic, stoked fear as a smokescreen and treated pre-emptive attacks as just.

Better late than never, Obama brought his lapidary logic and legal cautions to bear. “Neither I nor any president can promise the total defeat of terror,” he said. “We will never erase the evil that lies in the hearts of some human beings nor stamp out every danger to our open society.”

Conservatives can honk, as Senator Saxby Chambliss did, that Obama’s speech “will be viewed by terrorists as a victory.” But this president has killed more top Qaeda operatives than Bush did. While W.’s bullhorn vow after 9/11 to catch the “people who knocked these buildings down” plays every few minutes at his library, I couldn’t find any photos of Osama or acknowledgment of Bush’s failure to catch him. Obama’s library will have a wing for that feat.

You could fill an entire other library with what’s not in W.’s. Cheney and Rummy have been largely disappeared, and it is Condi Rice who narrates the 9/11 video. You won’t see the iconic “Mission Accomplished” photo, or that painful video in which W. keeps reading “The Pet Goat” to children after learning that America is under attack, or the notorious “flyover” photo of a desultory Bush jetting from Crawford to the White House and looking through the window of Air Force One at Katrina’s devastation.

Decision Points Theater — a whiny “Well, you try being the Decider” enterprise — lets you make the decisions after getting taped briefings on W.’s crises from actors playing experts. But it is rigged with so many false binary options that the visitors I voted with ended up agreeing with Bush’s patently wrong calls on Iraq and Katrina.

Mostly, aside from the word “freedom” reverberating endlessly, we see the kinder, gentler W. conjured by Laura the Librarian. The once-shielded twins are ubiquitous, as is Barney. (An interactive game lets you help Barney find his ball.)

The big display on W.’s stellar record on AIDS in Africa features a letter from the president on White House stationery with the salutation, “Yo Bono!”

You can be forgiven for thinking you’ve wandered into the Gore presidential library when you come upon a wall devoted to protection of the ocean and odes to “vital wetlands” and “marine habitats.” Who knew W. was passionately on the side of the humphead parrotfish?

Proving that the library is more a monument to Laura’s artful airbrushing than W.’s artless leadership, there’s a swank Café 43 with fancier fare than W.’s cherished PB&J’s, and a gift shop featuring Laura’s favorite books, from Dostoyevsky’s “Brothers Karamazov” to Truman Capote’s “Music for Chameleons.”

W. missed a bet not selling reproductions of his charming nude self-portraits and Barney paintings on posters, T-shirts and dog bowls. Far more interesting than packets of Texas bluebonnet seeds.

Since it’s Sunday we also have to deal with The Moustache of Wisdom:

Listening to the debate about President Obama’s health care plan, some critics argue that Obamacare is going to need Obamacare — because it’s going to be a “train wreck.” Obama officials insist they’re wrong. We’ll just have to wait and see whether the Affordable Care Act, as the health care law is officially known, surprises us on the downside. But there is one area where the law already appears to be surprising on the upside. And that is the number of health care information start-ups it’s spurring. This is a big deal.

The combination of Obamacare regulations, incentives in the recovery act for doctors and hospitals to shift to electronic records and the releasing of mountains of data held by the Department of Health and Human Services is creating a new marketplace and platform for innovation — a health care Silicon Valley — that has the potential to create better outcomes at lower costs by changing how health data are stored, shared and mined. It’s a new industry.

Obamacare is based on the notion that a main reason we pay so much more than any other industrial nation for health care, without better results, is because the incentive structure in our system is wrong. Doctors and hospitals are paid primarily for procedures and tests, not health outcomes. The goal of the health care law is to flip this fee-for-services system (which some insurance companies are emulating) to one where the government pays doctors and hospitals to keep Medicare patients healthy and the services they do render are reimbursed more for their value than volume.

To do this, though, doctors and hospitals need instant access to data about patients — diagnoses, medications, test results, procedures and potential gaps in care that need to be addressed. As long as this information was stuffed into manila folders in doctors’ offices and hospitals, and not turned into electronic records, it was difficult to execute these kinds of analyses. That is changing. According to the Obama administration, thanks to incentives in the recovery act there has been nearly a tripling since 2008 of electronic records installed by office-based physicians, and a quadrupling by hospitals.

The Health and Human Services Department connected me with some start-ups and doctors who’ve benefited from all this, including Dr. Jen Brull, a family medicine specialist in Plainville, Kan., who said that she was certain she had been alerting her relevant patients to have colorectal cancer screening — until she looked at the data in her new electronic health care system and discovered that only 43 percent of those who should be getting the screening had done so. She improved it to 90 percent by installing alerts in her electronic health records, and this led to the early detection of cancer in three patients — and early surgery that saved these patients’ lives and also substantial health care expense.

Todd Park, the White House’s chief technology officer, said many new apps being developed have been further fueled by the decision by Health and Human Services to make available massive amounts data that it had gathered over the years but had largely not been accessible in computer readable forms that could be used to improve health care.

It started in March 2010 when Health and Human Services met with “45 rather skeptical entrepreneurs,” said Park, “and rather meekly put an initial pile of H.H.S. data in front of them — aggregate data on hospital quality, nursing home patient satisfaction and regional health care system performance. We asked the entrepreneurs what, if anything, they might be able to do with this data, if we made it supereasy to find, download and use.” They were told that in 90 days the department would hold a “Health Datapalooza,” — a public event to showcase innovators who harnessed the power of this data to improve health and care.

Ninety days later, entrepreneurs showed up and demonstrated more than 20 new or upgraded apps they had built that leveraged open data to do everything from helping patients find the best health care providers to enabling health care leaders to better understand patterns of health care system performance across communities, said Park. In 2012, another “Health Datapalooza” was held, and this time, he added, “1,600 entrepreneurs and innovators packed into rooms at the Washington Convention Center, hearing presentations from about 100 companies who were selected from a field of over 230 companies who had applied to present.” Most had been started in the last 24 months.

Among the start-ups I met with are Eviti, which uses technology to help cancer patients get the right combination of drugs or radiation from Day 1, which can lower costs and improve outcomes; Teladoc, which takes unused slices of doctors’ time and makes use of it by connecting them with remote patients, reducing visits to emergency wards; Humedica, which helps health care providers analyze their electronic patient records, tracking what was done to a patient, and did they actually get better; and Lumeris, which does health care analytics that uses real-time data about every aspect of a patient’s care, to improve medical decision-making, collaboration and cost-saving.

Obamacare will be a success only if it can deliver improved health care for more people at affordable prices. That remains to be seen. But at least it is already spurring the innovation necessary to make that happen.

And if you think that your private health information is secure in your EMR you’re living in a dream world.  Now here’s Mr. Bruni:

Given what a mouthy thing I grew up to be, it’s shocking to me that I began talking later than most children do. But I didn’t need words. I had my older brother, Mark.

The way my mother always recounted it, I’d squirm, pout, mewl, bawl or indicate my displeasure in some comparably articulate way, and before she could press me on what I wanted and perhaps coax actual language from me, Mark would rush in to solve the riddle.

“His blanket,” he’d say, and he’d be right.

“Another cookie,” he’d say, and he’d be even righter.

From the tenor of my sob or the twitch of one of my fat little fingers, Mark knew which chair I had designs on, which toy I was ogling. He decoded the signs and procured the goods. Only 17 months older, he was my psychic and my spokesman, my shaman and my Sherpa. With Mark around, I was safe.

This weekend he’s turning 50 — it’s horrifying, trust me — and we’ll all be together, as we were at his 40th and my 40th and seemingly every big milestone: he and I and our younger brother, Harry, and our sister, Adelle, the last one to come along. We marched (or, rather, crawled and toddled) into this crazy world together, and though we had no say in that, it’s by our own volition and determination that we march together still. Among my many blessings, this is the one I’d put at the top.

Two weeks ago, the calendar decreed that we Americans pause to celebrate mothers, as it does every year. Three weeks hence, fathers get their due. But as I await the arrival of my brothers, my sister and their spouses in Manhattan, which is where we’ll sing an off-key “Happy Birthday” to Mark and drink too much, my thoughts turn to siblings, who don’t have a special day but arguably have an even more special meaning to, and influence on, those of us privileged to have them.

“Siblings are the only relatives, and perhaps the only people you’ll ever know, who are with you through the entire arc of your life,” the writer Jeffrey Kluger observed to Salon in 2011, the year his book “The Sibling Effect” was published. “Your parents leave you too soon and your kids and spouse come along late, but your siblings know you when you are in your most inchoate form.”

Of course the “entire arc” part of Kluger’s comments assumes that untimely death doesn’t enter the picture, and that acrimony, geography or mundane laziness doesn’t pull brothers and sisters apart, to a point where they’re no longer primary witnesses to one another’s lives, no longer fellow passengers, just onetime housemates with common heritages.

That happens all too easily, and whenever I ponder why it didn’t happen with Mark, Harry, Adelle and me — each of us so different from the others — I’m convinced that family closeness isn’t a happy accident, a fortuitously smooth blend of personalities.

It’s a resolve, a priority made and obeyed. Mark and his wife, Lisa, could have stayed this weekend in the Boston area, where they live, and celebrated his 50th with his many nearby college buddies. Harry and his wife, Sylvia, could have taken a pass on a trip to New York: they’re traveling all the way from the Los Angeles area, their home. But we made a decision to be together, and it’s the accretion of such decisions across time that has given us so many overlapping memories, which are in turn our glue.

I’m also convinced that having numerous siblings helps. If you’re let down by one, you can let off steam with another. “There’s always someone else to turn to,” said George Howe Colt, the author of “Brothers,” a 2012 book about brothers through history and about his own three siblings, all male.

“It’s like a treasure chest: you have access to a lot of different personalities,” Colt told me. “With my brothers, I turn to them all. But I turn to them for different things.” That’s how it is in our brood, too.

Perhaps because the four of us belong to the same generation — just over eight years separate Mark and Adelle — each understands the others better than our mother, now gone, could ever understand us, or than our father ever will. And while our parents gave us values, we inadvertently assigned ourselves the roles we play. Popularity came more easily to Mark, so I resolved to be the more diligent student, needing to find my own way to stand out. Because Mark and I made relatively conventional choices, Harry, for a while, made less conventional ones: his claim to a distinct identity.

That’s how it goes in a pack of siblings, and I sometimes wonder, when it comes to the decline in fertility rates in our country and others, whether the economic impact will be any more significant than the intimate one. For better or worse, fewer people will know the challenges and comforts of a sprawling clan.

Those comforts are manifold, at least in my lucky experience. With siblings to help shoulder the burden of your parents’ dreams and expectations, you can flail on a particular front with lower stakes and maybe even less notice. Siblings not only pick up the slack but also act as decoys, providing crucial distraction.

They’re less tailored fits than friends are. But in a family that’s succeeded at closeness, they’re more natural, better harbors. As Colt observed of his siblings, and it’s true of mine as well, they aren’t people he would have likely made an effort to know or spend time with if he’d met them at school, say, or at work. And yet a reunion with them thrills him more than a reunion with friends, who don’t make him feel that he’s “a part of a larger quilt,” he said. His brothers do.

My friend Campbell, who’s as fond of her two sisters as I am of my siblings, put it this way: “With a friend, I have to be more articulate. With my sisters, I can be my most primal self: inarticulate, childishly emotional. I’ll have a fight with my sister and say, ‘O.K., I know we’re in a fight, but I need your advice on something,’ and we can just put the fight on hold. They’re the only people in the world you can be your worst self with and they’ll still accept you.”

My siblings have certainly seen me at my worst, and I’ve seen them at theirs. No one has bolted. It’s as if we signed some contract long ago, before we were even aware of what we were getting into, and over time gained the wisdom to see that we hadn’t been duped. We’d been graced: with a center of gravity; with an audience that never averts its gaze and doesn’t stint on applause. For each of us, a new home, a new relationship or a newborn was never quite real until the rest of us had been ushered in to the front row.

This weekend we clap for Mark, and as I plot his dinner menu and hit the liquor store, I have to decode what he wants. It won’t be difficult. I have decades of history to draw from, along with an instinct I can’t even explain.

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