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The authors, Becker, Davis and Murphy, are from the University of Chicago. They point out that the uncertainty created by the Obama administration's programs including healthcare and social investments in education, energy conservation, and the desire to reduce carbon emissions, all tend to slow business expansion and investments to create jobs by putting additional costs on business. The expanding federal deficit and national debt also create additional uncertainty. Their point is that it was a mistake to start making major changes to transform the U.S. economy at this time, and that it would have been wiser to do these changes after the economy had recovered completely from the crisis. All efforts they say should have been concentrated on establishing conditions for a strong recovery. When combined with the lack of regulatory reforms to fix problems left behind from the crisis, and other failures, serious questions arise about how things will turn out in coming years. See Krugman- The Feeling of 1937, where Krugman takes this up from another angle, again with concerns about the future....

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The costs of fraud in medical care from spurious Medicare claims to kickbacks for unecessary services is estimated at $125 to 175 billion. Costs of unnecessary care from overuse to unnecessary lab tests are between $250-325 billion. The amount wasted for on treatment for preventable conditions such as heart disease and diabetes. is $25-50 billion. This number is much higher when all the complications from obesity are figured in. These amounts alone add up to $500 billion. Add to it the problems and the costs of medical errors leading to bad drug reactions or other misdiagnosed procedures which cost an estimated $75-100 billion and the the total is upto $600 billion. These amounts are not going to be tackled by computerization of medical records. The whole manner and ways in which medicine is practiced today and the manner in which the public takes care of its health would have to change for an impact to be made in these numbers.

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Steingart, senior correspondent of Der Spiegel, on the cost of a German style pension and healthcare system.

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Healthcare, climate change, pensions and social benefits, are three issues uppermost in the minds of German voters. Three million new young voters most of them only about 2 years old when Merkel started 16 years in office, look for change. They are well informed and for these young voters climate change is the most important issue. DW.com shows three voters and how they plan to vote. One voter has cast a mail in ballot for The Greens party. The second voter will vote for the Greens. Both because of climate change concerns. The third voter Thurid says her mother is a geriatric nurse and is not vaccinated. She is vaccinated but had talks with her mother and understands her worries about vaccination. She will vote for the Free Democrats because they oppose compulsory vaccination. The three leading parties for young voters are the Greens party, the Free Democrats, followed by the Social Democrats all in the range of 16-18% of support. The Greens have sent out 2 million brochures to voters. Out of 60 million voters in a German population of 80  million, 3 million is only 5% of the vote. What makes a difference is that it is consistent with the general direction of voters young and old, all looking for change in Germany as the CDU party attracts only about 20% or one fifth of German voters. Social Democrats Scholz is way ahead of Christian Democrats Laschet in how voters view each candidate. Will German voters be well informed enough to make a decision based on their desire for change after 16 years of Merkel or will the CDU bringing back in the last days of the campaign the old fears that the communist Left party would somehow find its way into the government using the Greens as a way in- this is a question for German voters. In1994 during the Cold War with Soviets Kohl used this to keep the Social Democrats out and Greens out and formed a coalition with the FDP. Yet today Merkel has grown close to both Russia and China and away from the Western alliance in a way that was unimaginable under Adenauer who helped build the new Federal Republic of Germany after the war. Merkel refuses to even immediately accept a call from a new US president Biden, American president who is closest in style and temperament to Harry Truman who faced off the Soviets in Berlin in 1948.  The FDP opposes a wealth tax or any form of taxes in which the wealthier pay a fair share of what is needed to build crumbling infrastructure in Germany neglected in the Merkel years. In Germany social and economic disparities have grown during the pandemic with poverty increasing during the pandemic as has happened throughout Europe and the world. The US is already committing to increase taxes for the upper incomes. This is where voters have a choice- do nothing with infrastructure, health or climate change or do something by increasing taxes. The choice is now before the German people.  With this question comes a choice for western civilization, with the recent election in the US, and two elections in Germany and then France. Will it look with optimism to the future or will it huddle up in a deeply cautious and slightly pessimistic view of the world that is embedded in Angela Merkel's cautious vision that ended up only responding to crises- some self inflicted as in migration policy, and even self inflicted in tackling euro problems created in the euro currency's faulty design. In fiscal policy as in migration policy Merkel has reversed her position- by supporting European solidarity. Will Germans vote for optimism or never ending caution? Are lessons learned?     ...

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The inflated costs for spinal surgeries at some hospitals in California. How surgeons, doctors, consultants, distributors and hospitals operated in a flawed system to make revenue gains through overbilling, and focus on increasing the number of surgeries performed.

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Bob Kocher, special assistant to President Obama for healthcare policy in 2009-2010 describes how hospital mergers with the passage of the Obama Healthcare Law are not doing much to control health care costs in the U.S. This is contrary to what was expected during the policymaking in 2009. In 2015 there were 112 hospital mergers in the U.S.  He says smaller physician led health care organizations do better at taking steps to improve productivity, adopt technological improvements and control costs.

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Lipton, Austin and LaFraniere of the NYT tell the story of how the serious differences between the prime contractor for the federal healthcare website, CGI Federal, and the Obama administration officials handling the website, evolved into conflicts that could not be resolved. This led to the flawed website being rolled out on schedule ignoring serious problems with the website. The detailed report comes after interviews with Obama administration officials and specialists who worked on the project and looking into government and contractor documents. A month ago in October 2013 the healthcare website for the Obama healthcare law was up only 42% of the time with 10 hour failures happening frequently. Basic steps for the functioning of website backup systems in case there is a failure, testing to ensure negligible or no outages, were not secured. The government officials responsible for the rollout did not have the capabilities to handle such a project. Henry Chao, who worked in the Medicare agency for 19 years was left to oversee day to day questions for the website HealthCare.gov, but lacked a formal background in software engineering and no authority to make the decisions needed. The $630 million project was setup inside the Medicare Agency, instead of a separate agency specially setup for this project and staffed with the appropriate skills as originally proposed. Five different lower level government officials made decisions without the authority needed and no one person with the necessary skills was given overall responsibility and decisionmaking. A series of missteps were allowed to take place- settting many added requirements that made it difficult for contractors to focus on basic steps and get them right, use of the MarkLogic database system instead of systems from IBM or Oracle against the advice of contractors, multiple contractors without a way to control the overall project, shifting requirements from the government and bureaucratic delays for resolving basic issues such as use of social security numbers, all worked to create delays. With the delays came a deterioration of relations between Obama administration officials and the contractors. The government officials response was to stick to the deadline of Oct. 1 rollout, with Michelle Snyder, chief operating officer of Medicare agency telling people she would fire the contractor if possible. In the end no one took responsibility for a safe reliable rollout, even though the system failed a test of 500 users in late September and was down half the time in mid-October. President Obama or his advisors were either not kept fully informed, or did not grasp the significance of the collapse in relations between contractors and the government and a project out of control. His aloof distanced approach was not an asset in such matters- saying about the rollout and use of the website: "this is real simple" like using the Kayak website for travel bookings- and he saw no need to take action leading to the major failure for the administration that followed....

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David Wessel points to some problems with the Paul Ryan budget proposal. Ryan's plan does not balance the budget till after 2030, and Congress would have to raise the debt ceiling each year till then. The changes to Medicare Ryan proposes would limit how much the government spends, but the savings from this do not come for a decade, as people expected to retire in the next 10 years will still have Medicare. Ryan's proposal shows how deep the cuts will have to be if deficit reduction is done without raising taxes. Pete Domenici and Alice Rivlin who developed a deficit reduction plan, said they were disappointed that the Ryan plan "fails to address the need for new revenue," which they consider crucial for truly tackling deficit reduction. The Obama budget failed to offer a comprehensive deficit reduction plan, leading to openness for new ideas. The health care delivery system in the U.S. needs to be efficient and costs need to come down. Ryan's proposal gives no idea where the efficiencies will come from. Would they come from competition between private insurers? How will escalating healthcare costs be controlled. Another consideration is that even with its problems Medicare is less costly to administer than private insurance. Everything depends on seniors shopping vigorously for the best premiums because risks and costs are borne by seniors, with the idea that this will somehow control escalating medical costs....

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Serious problem of rapid premium increases for middle class people not eligible for subsidies under the Affordable Care Act. Insurance companies have increased premiums rapidly to pay for the cost of treating people with previous conditions and the uninsured, as well as population with poor health conditions.

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Ron Wyden, Democratic Senator from Oregon, on maintaining competitive choice for 200 million Americans who have to buy insurance outside the Exchange proposed in many of the bills being put forward in the U.S. Congress. This lack of choice between seriously competitive plans will leave the situation in the same way that it is today, with little hope for controlling runaway costs and doom health care reform. The key to controlling costs says Wyden is introducing choice and competition. Wyden will introduce this plan as an amendment called Free Choice to legislation being debated in Congress.

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G-7 nations reach agreement for a global minimum tax of 15% a floor for taxes that the Biden administration finds acceptable. This agreement was reached at a meeting of the Treasury chiefs of the 7 G-7 countries in London on June 5, 2021. The G-7 countries are Canada, France, Germany, Italy, Japan, UK, and US. Next agreement from Russia, China, India and Brazil in the G-20 nations would establish new ground rules for the major economies. The G-20 meeting is in Venice July 9-10. The OECD is steering the international efforts to achieve that goal. For the agreement to be effective a number of small nations that use tax rates of below 15% to attract business have to be part of the new rules. One of these countries is Ireland with a tax rate of 12.5%. For the Biden administration in the US the goal is a significant one as president Biden seeks business to pay its fair share so that long neglected priorities for education, healthcare, infrastructure, post pandemic improvements can be met. France and other nations in the EU face similar needs in the post pandemic environment. By setting a floor the Biden administration is both creating a new cultural concept of fairness in taxation and making it possible to finance the $2 trillion spending programs for these priorities of president Biden. Behind this are important facts that have left the large tech businesses paying little or no tax depriving governments of the very revenues that are needed for infrastructure and services for a modern well run state. The Biden administration seeks to include the tech businesses as well as all businesses in the new tax rules so that a uniform idea of fair taxation applies across the whole economy for the first time in two decades. In this way it makes up for the missed opportunities in the OBC administrations of Obama, Bush, Clinton that have led to loss of faith in the state and institutions in the US. A similar situation prevails in the UK,  France and Germany where previous administrations failed to address this important issue of fair taxation and financing infrastructure and priorities in health, education, and critical needs of the people.   ...

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One in six dollars generated by the U.S. economy goes to pay for health care, almost twice the average for rich countries. It hurts America in many ways; by being a burden on the taxpayer when it comes to Medicare and Medicaid paying for the poor and the elderly, on companies being one reason GM went bankrupt, it eats up federal and state budgets, rising costs make any form of future coverage for all unsustainable, and it robs other priorities such as infrastructure building and other national scale investments. The Economist says that if it had to design a system from scratch, it would go for a system based mostly around publicly funded health care. For the uninsured the solution of an employer mandate is now well accepted, so this is not an issue. What is an issue is how to make the new system affordable? Here the Economist says that whether in stages or in one move, the tax deductability of employer paid health insurance, which is costing the U.S. government $250 billion ayear, has to go. It is necessary to remove this deduction, and its something all interests involved will have to swallow, as other savings are smaller and will not be adequate. The deductability of insurance makes the true cost of insurance transparent, so it supports gold plated insurance. This does not make cost control the pressing priority it needs to be. So the deducatability of employer paid health insurance hurts both ways. The other necessary action is in the area of moving out of the current culture where most doctors work on a fee-for-service basis, where the more tests they prescribe or procedures they perform the greater their incomes. This acts as a perverse incentive, and has aruinous effect in mushrooming health care costs in America. Cutting back on unnecessary tests and procedures, and prescriptions , would save 10% to 30% of health costs says the Economist. And it says this has been proven with the Mayo Clinic in Minnesota and Kaiser Permanente in California showing that cutting back doesn't hurt care and outcomes., so much so that cutting back would occur along with improved outcomes. But Americans with employer paid insurance just take things for granted as its not much out of pocket expense for them. THis creates the lack of a force for controlling costs even as employers are shouldering abigger and bigger burden, and the employee who thinks he is doing fine actually is seeing more of his salary dollars going to pay for his health insurance. In a way the consumers of health care are stuck with the perception that they are not somehow paying for these mushrooming costs and too manytests, procedures and prescriptions. This perception leads them a false sense of comfort with the system they are in, and a fear of something new fanned by the medical lobbies, that any change will impact users negatively. This makes the whole discussion on health care or the process of finding solutions to become an exericize in which terms like "rationing" and "choice" play a distorting role. ...

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A study by Dr. McCormick of the Harvard Medical School and professors at the City University of New York School of Public Health at Hunter College, shows that the anticipated savings from conversion to medical records may not materialize to the extent expected. This study of data from 1100 doctors of 28,000 patient visits shows that with access to digital records doctors actually increased the number of tests ordered- from 12.9% of visits without digital records to 18% of visits with digital records. For more advanced tests such as MRI and CT scan the rate was 70% higher. Dr. McCormick says this may be because the new digital technology may have made it easier to order tests.

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Ken Murray, a retired family medicine professor at the University of Southern California, describes how doctors address the option of prolonging life when the prospects of survival improve say from 5% to 15%. The choice is based on the human need to find closure in an atmosphere that gives comfort, a sense of peace and a sense of place with home and family, with hospitals not deisnged to and not able to perform that role. Murray gives the example of his cousin Torch, who he says was born at home by the light of a flashlight, who decides to not choose aggressive treatment, which would have prolonged his life for no more than 4 months. Instead he spent the next 8 months with family and did everything he could do with the 8 months that made for quality of life, rather than just choosing quantity in and out of hospitals. He died peacefully in his sleep. The heroics in and out of hospitals would actually have deprived the patient of the opportunity to reach a sense of closure that comes from the comfort of home, family, and arriving at a sense of peace....

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Issues raised by the huge mismatch between revenues and investment for AI. $400 billion estimated investment by 5 Tech firms in 2025 alone with revenue of about $40 billion and huge uncertainty about when AI will produce returns. Articles seen this week of November 17 in the WSJ and NYT on this issue, podcasts, discussions in other media outlets. Could this lead to a dot com bubble type economic crisis? Could that lead to a recession? Alongside these articles another article in the WSJ on Nov 17 shows the benefits small firms get by using AI, benefits which are on the fringes of their business, not essential but with some experimenting firm owners/managers able to tweak AI information for use in business. Nothing significant which firms will pay much money for. The uncertainty is a major factor. Should geopolitics trump all these concerns? Is the competition with China require this scale of investment, and is China following a more utilitarian approach as reported in a WSJ article this month, of investing in AI in a utilitarian way targeting its use in improving manufacturing, improving infrastructure, and not wildly throwing money at experimental uses that are unlikely to yield much result. In geopolitical sense would the country that not only promoted AI but used it efficiently and cost effectively, used it in ways that promote the overall public good, get the WIN. In short it behooves everyone of us to ask hard questions of AI, to dehype the hype, to look for the public good that comes out of this from it's efficient use. To ask the tough questions when $400 billion generates only $40 billion in 2025 and the $3 trillion planned investment over 5 years is half unfunded, is it going to crowd out energy needs for homes and business, push renewable energy targets back, crowd out essential investments in the crumbling aging infrastructure of the US and Europe, crowd out essential investments in education, healthcare, pharmaceuticals, and manufacturing, that hold better promise for our People. Will it also put retirees at risk when corporate bonds from retirees money fund the unfunded portion of AI? This means making the political dimension not about migration, settling the illegal migration issue that was meant to be settled a long time back, or about cultural issues that have little day to day impact on our lives which are about groceries, childcare, housing that are non ideological. Making the political dimension not about remote countries that one knows little about except when it affects public safety and health as with fentanyl. Capital allocation decisions to the vital needs of America can then be free of politically induced error, so that it can be subjected to the test of how best it serves the public interest and the people of the Nation. ...

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A critical part of the Affordable Care Act is the setup of marketplaces or exchanges to let people without insurance buy individual health plans. Some states setup their own exchanges, and some states let the federal government step in and run them. To help the lower middle class and poor the Act provides health subsidies to buy insurance in the exchanges, and 85% of customers in the exchanges qualify for this benefit. The U.S. Supreme Court voted 6-3 in 2015, compared to a tight vote in 2012 on the Affordable Care Act, to maintain the health subsidies. Justice Roberts wrote the majority opinion, saying "Congress passed the Affordable Care Act to improve health insurance markets, not destroy them." Justice Scalia dissented calling it "interpretive jiggery-pokery." Justices Clarence Thomas and Samuel Alito Jr. dissented. Voting in favor were Justices Anthony Kennedy, Ruth Bader Ginsburg, Stephen Breyer, Sonia Sotomayor, Elena Kagan, Justice Kennedy dissented in the 2000 case. The challengers petition to the courts was based on a reading of phrases in the Affordable Act which had not occurred to the writers of the law. The reading suggests only people enrolled in state setup exchanges are eligible for subsidies. If the Supreme Court ruled in favor of the plaintiffs the 6.4 million Americans who are enrolled in the federal exchanges would lose the subsidies provided under the law and lose health insurance. And the economic foundations of the Affordable Act would be undermined with insurance companies required to provide insurance to all regardless of pre-existing conditions and subsidies removed, leaving the companies with sicker pool of customers resulting in destabilizing the exchanges and higher premiums. The court ruled in favor of an interpretation that is compatible with the whole law and the intentions of the statute to help the middle class and the poor buy health insurance. The chaos in the insurance markets that would result in going with the plaintiffs because of a careless writing of a phrase, was uppermost in the majority's mind. Chief Justice Roberts emphasized this, saying- "The statutory scheme compels us to reject petitioners' interpretation, because it would destabilize the individual insurance market in any state with a federal exchange and likely create the very 'death spirals' that Congress designed the act to avoid." This case originated with 4 plaintiffs from Virginia who challenged the IRS regulation that said subsidies were allowed regardless of whether the exchanges were run by the state or the federal government, arguing that this was at odds with the particular phrase in the law that was ambiguous about federal exchanges eligibility for health subsidies. Judge Roger Gregory of the Fourth Circuit Court of Appeals in Richmond, Virgina, ruled that the phrase was indeed ambiguous, but the IRS was owed deference in its opinion. Chief Justice Roberts made it clear that this was not a case for the IRS, saying "it is instead our task to determine the correct reading." ...

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Kathleen Sebelius, a former Governor of Kansas, pushed forward implementation of the Obama Healthcare Law as U.S. Health and Human Services Secretary, 2008-2014. She resigned in 2014 after IT problems made it difficult to use the government's Healthcare.gov website in 2013.

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The EU's competition commissioner to crackdown on pharmaceutical companies that are delaying the entry of generics drugs with various tactics that are anticompetitive. EU has raided the offices of several marge drug companies and retrieved documents that show this activity was going on. About 5% of medical bills or 3 billion euros coud have been saved from 2000 to 2007, if companies had allowed generics to enter the market earlier and not resorted to these antitcompeitive strategies. Like paying off generics companies or having so many patents on the ingredients of the drug, in one case 1300 patents on one single drug, and then suing the generics companies to tie up the case in the courts.

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The Economist quotes experts saying that drug innovations would not be affected by price controls on drugs. Pricing reforms can accomplish the reverse, spur innovation by doing as Britain and Germany are doing- pioneering comparitive reviews of drugs effectiveness and cost-benefit analyses aimed at reimbursing firms for new drugs based on their performance. Sanford Bernstein, a financial advisory firm, says in its study that a 20% reduction in what Medicare pays for drugs would not kill off innovation, it would reduce earnings per share of big pharma firms by 3-8%. As drug research is now done in many countries, and its a globalized industry, innovation is not likely to be automatically affected by price reductions in one country like the USA, according to Alna Garber of Stanford University and Patricia Danzon of Wharton Business School.

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 Americans in the southern states forget that president Kennedy made the famous statement about "a rising tide lifts all boats" in Arkansas, a poor southern state, saying that America must invest in all regions in people in all parts not just in well off northeastern states. In a handful of southern states expanding Medicaid to about $43,000 or 138% of the federal poverty level for a family of four is now being taken up by Republican leaders who show new openness- in Alabama, Georgia and Mississippi. Noah Weiland -of NYT looks at one particular battle -between Democrat Governor Laura Kelly in Kansas and Republican Speaker Hawkins- in Topeka, Kansas, where the fight goes on. Hawkins calling it the greatest Ponzi scheme devised and Kelly telling this reporter that she has included a work requirement so there is no excuse for not doing this. Republicans are coming around and so are states in other places. Missouri, Nebraska, and Oklahoma, states that lie next to Kansas have approved this through ballot initiatives. The point here is that in the years as America comes out of the pandemic there is and should rightly be a realization that this is different, that the children of low income families deserve as equal a chance as their higher income fellow Americans, that depriving them of good medical care makes America a weaker country. As Jerome Powell of the US Fed said in Stanford today about Kennedy's expression of "lifting all boats," it is just this that is needed today. It will be the No.1 election issue in Kansas in 2024, says Governor Kelly. The Republicans are also having second thoughts and are now just face saving. Consider that the Kansas Health Institute a research group, says 70% of the people becoming eligible for Medicaid expansion are working. Many are restaurant business workers who cannot provide proper medical care to children who form the next generation of America. And hiring in rural hospitals would expand for health workers instead of layoffs in southern states lifting financial strain on rural healthcare with additional Medicaid funds. This helps rural America when it needs it most. ...

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Azam Ahmedjan provides this insightful account of how the Taliban in 2015 has changed. It is no longer the old Taliban the U.S. faced following 9/11 attacks. The aging leadership in Patkistan no longer has the same level of control in Afghanistan. The older Taliban leadership inside Afghanistan has been killed in fighting with American led forces and drone strikes, leaving younger, less disciplined and fractured groups inside Afghanistan. This is the Taliban the American supported government faces. Most importantly the expectations of the Afghan people have changed. This makes it harder to negotiate a peace agreement with fractured Taliban groups on the ground. It also creates new opportunities for integrating Afghanistan into the fabric of South Asian society, as people in India and Pakistan are eager to see modernization, building of infrastructure, education, healthcare, and better standards of living after years of conflict.