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This is an exceptionally humorous operating room story of Dr. Trump and Dr. McConnell by Kristof of the NYT. Sometimes humor tells the story- and Kristof does this using a story of a surgeon president Trump in the operating Room trying to address the concerns of the patient Janet, as he keeps telling her she needs a new heart with great benefits, great benefits, before she implodes or goes down failing. Flat out take the old heart out even if a replacement hasn't been found, believe me great benefits the surgeon tells her, just that the patient just isn't getting convinced as its happening to her. The analogy is with replacing a health care plan, not just the Obama plan, any plan without something to take its place. For a few days before this article by Kristof, the Republican effort to repeal the Affordable Care Act without having a replacement was presented as a good idea. Janet is like the three Republican women- Collins of Maine, Capito of West Virginia, and Murkowski of Alaska who wanted to keep the heart they had till a replacement was found, against the surgeon Trump's advice. In a way it is about politicians in the last decade who never had any discussions as they rushed through with their own agendas, as the Republican and Democratic health care plans were rushed through Congress with relatively little participation and debate to hear all viewpoints. ...

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Mr. Trump's conflict with the Justice Department in the last weeks of his presidency to appoint a new Attorney General with intent to contest the results of the presidential election of 2020, is shown in this report in NYT. This created risks for American democracy. The cracks in social cohesion following four decades of foreign wars 1980-2021, irresponsible behavior of financial institutions leading to financial crises and impoverishment of America, incompetent elites, neglect of rural America, ceding of technology and competitive position to China, failure to fund education, healthcare and infrastructure, under presidents Reagan, elder Bush, Clinton,  Bush, Obama, led to a situation of revolt against the status quo by a maverick politician using a new and proven dangerous form of communication social media. Ultimately this put democracy at risk. Lessons from this are only now being learned as people in the Biden administration and outside of it reflect on what happened. In this WSJ report Mr. Trump is seen pressuring officials of the Justice Department to agree to appointment of a new Attorney General shortly after the election. This was seen as an effort to question the results of the 2020 presidential election. A leading senator on the Judiciary Committee says this would lead to "shredding the US Constitution to stay in power." Of this and also of four decades of neglect in America Washington has this to say in his first Inaugural Address on April 30, 1789- "The blessed religion revealed in the word of God will remain an eternal and awful monument to prove that the best institutions may be abused by human depravity; and that they may even in some instances be made subservient to the vilest of purposes. Should, hereafter, those entrusted with the management of this government, incited by the lust of power and prompted by the supineness or venality of their Constituents, overleap the known barriers of this Constitution, and violate the inalienable rights of humanity: it will only serve to shew, that no compact among men (however provident in its construction and sacred in its ratification) can be pronounced everlasting and inviolable- and if I may so express myself, that no wall of words, that no mound of parchment can be so formed as to stand against the sweeping torrent of boundless ambition on the one side, aided by the sapping current of corrupted morals on the other." ...

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The Economist cautions that recovery is nowhere in sight, the hope points to only amoderating of the steep downturn. The 20% rise in the stock market for two thirds of the 42 stock markets that the Economist tracks in the past 6 weeks, can easily fizzle out as has happened before. Between 1929 and 1932 the Dow Jones Industrial Average went up more than 20% four times only to fall back to previous lows, and this crisis has seen 5 separate rallies of more than 10% only to fall back. But toxix assets have not been cleared up at Us and European banks, And consumption in the US, Germany, Japan and China shows no signs of coming back for years especially in the US where saving is increasing. And European banks have about $1 trillion in losses in central and Eastern Europe that have not been recognized, and the slide in the British and Spanish economies proceeds. And developing cpuntries have $1.8 trillion worth of borrowing to roll over this year, with less access to foreign investment. At one point the emerging countries imported capital worth 5% of their GDP, now cautious investors will keep that money at home. In America rising foreclosures and rising unemployment, combined with lower consumption, will keep economic growth down for years. Rising debt will limit future fiscal stimulus in countries like Japan and the US. Chinese growth will be constrained by its overdependence on infrastructure spending and lack of serious changes to its healthcare system which makes consumers save more for medical crises....

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U.S. health insurance company WellPoint Inc. will offer higher payments to primary care physicians. This is part of new strategy to reduce emergency room visits and costs after deterioration in a patients condition by relying on primary care physicians for better care at the outset. Payments to primary care physicians will be increased by 10%, with higher payments when the results show better quality and preventive care. WellPoint has a network of 100,000 primary care doctors. Physicians who meet certain goals such as lowering the overall cost of a patient's health care costs will be given an incentive of 20-30% of the savings realized. The new effort will add 1-2 percentage points to the 6-8% of the $100 billion that Wellpoint pays for claims processed each year. WellPoint's management sees a reduction in medical costs of about 20% by 2015 as a result of such efforts.

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Senators Mike Lee of Utah and Jerry Moran of Kansas declare their opposition to the Republican Health Care bill proposed by Senator McConnell. This decision by the two senators makes it impossible to begin debate on the bill. Earlier two other senators, Susan Collins of Maine and Rand Paul of Kentucky announced their opposition. This means the Republican health care bill has no chance in the Senate even after changes to the bill passed by the House of Representatives. Republicans have a thin majority in the Senate make it difficult to pass legislation. Collins met with residents in Maine and Moran with people in his home state of Kansas, and both senators heard a lot about the negative effects of the Republican bill on people in their state. The bill is seen as hurting people in rural areas, elderly, and not likely to do enough to bring down premiums. Its plan to slash Medicaid spending has drawn strong opposition from all Democrats.

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The health care system is designed to encourage procedure based specialist practices and discourages the patient understanding education and monitoring that occurs with a well designed preventive family physician practice. As a result a patient only spends 30 minutes ayear on average with family physician compared to one hour in other developed nations. In the USA there has been a steady decline in the level and quality and extent of family care and the close one on one rapport with well trained family physicians who enjoyed their work and understood their patients and kept up with their health conditions and provided good and regular advice on these conditions. There is no money in this care as a result first you provide an environment where a whole range of medical conditions can flourish and expand, and then you hit them with a whole series of tests to rule out specific medical conditions. It is a perfect way to expand the testing and let testing flourish, so it would appear that if someone had wanted to start with a goal of letting testing proliferate unhindered then this would be the perfect way to design it. ...

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Drug companies spent $168 million on lobbying in 2007, up 32% from 2006, according to the Center for Public Integrity. The biggest spender is the Pharmaceutical Research and Manufacturer's Association of America which paid $23 million, a 26% rise from ayear earlier. Amgen was first among drug firms at $16.2 million, Pfizer at $13.8 million, Roche at $9 million, Sanofi-Aventis at $8.4 million, GlaxoSmithKline at $8.2 million, and Johnson & Johnson at $7.7 million. In 2006 Democrats received 31% of the industry lobbying funds, now with Democrats controlling Congress the shift is to more money given to Democrats.

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Bernie Sanders tells his supporters at the Democratic National Convention in Philadelphia that "immediately right now, we have got to defeat Donald Trump, and we have got to elect Hillary Clinton and Tim Kaine." He says this campaign was not about just electing a president but about transforming the country. And for this he was planning to back about 100 candidates with similiar thinking across the U.S. He called on supporters to continue the campaign for social, economic, racial and environmental justice. Voters for Sanders were offended by the information shown in DNC email leaks of the bias against Sanders shown by DNC chair Debbie Wasserman Schultz, who has since resigned.

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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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The U.S. House of Representatives votes to repeal and replace the Affordable care Act 217-213. Moderates were won over by an addition of $8 billion  to add coverage for a popular feature of the ACA that covered people for pre-existing conditions.  The bill that passed gives credits of $2000 to $4000 a year, depending mostly on age, upto $14,000 for a family. Credits are reduced for individuals making over $75,000 a year or families making over $150,000. There is no mandated insurance coverage. This trims the federal budget deficit, yet also is expected to keep 24 million more Americans without health coverage after 10 years. The bill now goes to the Senate where moderate Republicans are worried that this may increase premiums for older people, one of the drawbacks of the earlier version of the House Republican bill.

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The Republican House health care bill AHCA  keeps some some of the more popular parts of the Affordable Care Act such as not taking pre-existing conditions to deny insurance, keeping children covered on parents insurance till age 26, and increase contributions to Health Savings accounts. It is different in that the expansion of Medicaid at 138% of poverty rate threshold is rolled back. Age is used for tax credits instead of income, hitting those approaching Medicare age harder. The maximum charged to older people is now set at  5 times compared to 3 times what young have to pay. In general the Republican bill is seen as targeting the elderly to keep premiums down. The elderly on low incomes are hit hardest. Fox News O'Reilly Show showed the host questioning House Republicans, citing the CBO estimates that elderly on low incomes may have to pay as much as $14,000 a year for insurance making it basically unaffordable, and 52 million Americans would be affected adversely. Large companies are no longer required to offer mandatory health insurance under the new bill. Conservatives from Freedom Caucus wanted to see the essential areas of benefits covered by the law limited to fewer than the ten areas in the Affordable Care Act. The ACHA Republican bill leaves to states to determine what are required essential benefits. At one point maternity benefits were to be dropped but this was changed to let states decide. As a result the bill is 33 votes short of the number needed for passing the house in March 2017.   Neither the Democrats Affordable Care Act or the Republican House bill of Speaker Ryan do much to tackle the real problem- the absolute amount and increases for health care dollars for treating each disease in the U.S. compared to European and other countries. As a result health care has become more of a partisan struggle between the two parties than a real effort by all to overcome the problems that have to be tackled. Republicans want to see premiums drop and keep the burden on the deficit down- but with the level of U.S. health care costs disproportionately high compared to Europe and the rest of the world the arithmetic is tough and ends up leaving out vulnerable groups such as the elderly on low incomes, thus making the whole proposition prone to fail. For the same reason the Democrats failed to keep premiums down with a wider safety net leading to calls for repeal of their version.   ...

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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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NYT reports show the Republican health care bill AHCA 33 votes short of passing the House and likely to fail. Conservative Republicans were looking to whittle down the safety net in the Affordable Care Act, and moderate Republicans could not stomach the whittled down bill removing guarantees of essential benefits for instance. The basic problem- no real consensus among Americans about providing health care to all Americans, and no real solutions possible as long as there is acceptance of disproportionately high levels of medical care costs for treating each disease in the U.S. compared to Europe and other countries.

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A Pew Research poll shows Democratic voters now favor a bold ambitious agenda by large margins. Voters seeking compromise swung sharply going downwards from 69% to 46%. Many are calling for Medicare for All. In the Republican Party the shift is slight from 46% to 44%.

In the House the Congressional Progressive Caucus now has about 90 members. Of the 50 newly elected members who are House Democrats 20 are part of this Caucus pushing for bold action.

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Lobbying by the American pharmaceutical industry and the Obama administration. Emails showing the negotiations between the administration and the pharmaceutical companies.

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With the rushed approach adopted by the Trump administration not enough consideration was given to winning support in the House from 25 conservatives in the Freedom Caucus. Without their support the bill cannot be passed in the House of Representatives. The fight also includes one over what are essential health benefits including whether  maternity care would be included. As a result some moderate Republicans are also expressing opposition on the grounds that less people will be covered and fewer benefits will be provided under the Republican House plan called AHCA. President Trump has not involved himself in the details, and the bill comes very early in the first 100 days, leading to the perception that health care has become a partisan conflict without really grappling with the problems of high cost of health care and creating a solution that all can support. Democrats are seen as having made the same error early in Obama administration's first term. President Trump sees this as a much needed win with a drop in his approval ratings, making this even less of an effort to come out with a good plan.  ...

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Baer describes the role played by Jeb Bush at Lehman, the sensitive moments when Lehman was near collapse and Lehman executives suggested Dick Fuld, the CEO, should talk to his brother George W Bush, the U.S. president. According to Baer this call was never made because of the odd position it would place the two brothers in. Jeb Bush made a trip to Mexico City to meet Carlos Slim, a telecom billionaire, seeking investment prior to Lehman's collapse. Bush was paid $1.3 million annually for his work at Lehman, and after Lehman was acquired by Barclay's bank $2 million annually. Bush worked under Steve Lessing, a key fund raiser for his brother George W. Bush, at Lehman and Barclay's. The work involved talking to clients including healthcare companies Cigna, insurance company MetLife, and other clients. About half of Bush's time was spent working at the bank as an adviser, not an employee. The only other candidate for president in 2016 who worked at Wall Street, Ohio governor John Kasich, also worked at Lehman from 2001 to 2008. Kasich was reportedly paid $182,000 and a bonus of $432,000 as managing director at the investment banking division, less than Jeb Bush but working full time. When Jeb Bush graduated from the University of Texas in 1974 he worked at Texas Commerce Bank, founded by James Baker III, a close friend of his father George H.W. Bush. He worked there from 1974 to 1980, in the international division looking at country risks in Latin America. Both Jeb Bush and Kasich face the prospect of facing difficult questions about their time at Lehman Brothers, because of the 2008 financial crisis and aggressive leveraged expansion at the bank leading to its collapse....