America's defining choice: war in Afghanistan or health care at home

President Barack Obama and Congress will soon make defining choices about health care and troops for Afghanistan.

These two choices have something in common — each has a bill of around $100 billion per year. So one question is whether we're better off spending that money blowing up things in Helmand province or building up things in America.

The total bill in Afghanistan has been running around $1 million per year per soldier deployed. That doesn't include the long-term costs that will be incurred in coming decades — such as disability benefits, or up to $5 million to provide round-the-clock nursing care indefinitely for a single soldier who suffers brain injuries.

So if Obama dispatches another 30,000 or 40,000 troops, on top of the 68,000 already there, that would bring the total annual bill for our military presence there to perhaps $100 billion — or more. And we haven't even come to the human costs.

As for health-care reforms, the 10-year cost suggests an average of $80 billion to $110 billion per year, depending on what the final bill looks like.

Granted, the health-care costs will continue indefinitely, while the United States cannot sustain 100,000 troops in Afghanistan for many years. On the other hand, the health-care legislation pays for itself, according to the Congressional Budget Office, while the deployment in Afghanistan is unfinanced and will raise our budget deficits and undermine our long-term economic security.

Doesn't it seem odd to hear hawks say health reform is fiscally irresponsible, while in the next breath they cheer a larger deployment of troops in Afghanistan?

Meanwhile, lack of health insurance kills about 45,000 Americans a year, according to a Harvard study released in September. So which is the greater danger to our homeland security, the Taliban or our dysfunctional insurance system?

Who are these Americans who die for lack of insurance? Dr. Linda Harris, an OB/gyn in Oregon, tells of Sue, a 31-year-old patient of hers. Sue was a single mom who worked hard — sometimes two jobs at once — to ensure that her beloved daughter would enjoy a better life.

Sue's jobs never provided health insurance, and Sue felt she couldn't afford to splurge on herself to get gynecological checkups. For more than a dozen years, she never had a Pap smear, although one is recommended annually. Even when Sue began bleeding and suffering abdominal pain, she was reluctant to see a doctor because she didn't know how she would pay the bills.

Finally, Sue sought help from a hospital emergency room, and then from the low-cost public clinic where Harris works. Harris found that Sue had advanced cervical cancer. Three months later, she died. Her daughter was 13.

"I get teary whenever I think about her," Harris said. "It was so needless."

Cervical cancer has a long pre-invasive stage that can be detected with Pap smears, and then effectively treated with relatively minor procedures, Harris said.

"People talk about waiting lines in Canada," Harris added. "I say, well, at least they have a line to wait in."

Based on the numbers from the Harvard study, a person like Sue dies as a consequence of lack of health-care coverage every 12 minutes in America. As many people die every three weeks from lack of health insurance as were killed in the 9/11 attacks.

Health coverage is becoming steadily more precarious as companies try to cut costs and insurance companies boost profits by denying claims and canceling coverage of people who get sick. I grew up on a farm in Yamhill, Ore., where we sometimes had greased-pig contests. I'm not sure which is harder: getting a good grip on a greased hog or wrestling with an insurance company trying to avoid paying a claim it should.

Joe Lieberman, a pivotal vote in the Senate, says he recognizes that there are problems and would like reform, but he denounces "another government health-insurance entitlement, the government going into the health-insurance business." Look out — it sounds as if Lieberman is planning to ax Medicare.

The health-reform legislation in Congress is imperfect, of course. It won't do enough to hold down costs; it may restrict access even to private insurance coverage for abortion services; it won't do enough to address public health or unhealthy lifestyles.

Likewise, troop deployment plans in Afghanistan are imperfect. Some experts think more troops will help. Others think they will foster a nationalist backlash and feed the insurgency (that's my view).

So where's the best place to spend $100 billion a year? Is it on patrols in Helmand? Or is it to refurbish our health-care system so that people like Sue don't die unnecessarily every 12 minutes?

Nicholas D. Kristof is a regular columnist for The New York Times.