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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 4.30 or 5.30 wakeup routine where one goes to sleep between 9.00 and 9.30 pm is one that gives time for fitness, a chance to so something for oneself before daylight and before the world wakes up. This report is in Style in WSJ when it should be in the Health and Wellbeing section. Rising early is part of yoga tradition for meditation in India where it is called Brahmamurta (time of Brahma) generally between 3.30 am and 5.30 am in the early morning. It is the time of the Creator of the universe, Brahma.

It is the best time for meditation on Ram, Brahman, on Christ or the Buddha. It can also be used for creative activity and for work that require concentration and clarity of mind. When the whole world sleeps the sage is awake, says the Bhagavad Gita. In Christian churches this is also the time for early morning prayer.

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WSJ reporter Monica Langley provides a glimpse behind the scenes of how Donald Trump comes up with his attacks on rivals, and statements on immigration, terrorism, refugees. Trump pays close attention to what is riling voters on any particular week, but other rival politicians are not willing to say. He looks for what resonates with the public, and in today's environment where politicians are cautious, careful and plodding, this strategy works. Donald usually puts down a few points on his private plane, looks at reports from campaign staff, yet makes all the decisions himself on what and how to say it. His memory helps, he says. And he has a flair for words, sounding uncouth at times, but yet choosing words carefully enough to sound reasoanble to his audience. In Jan 2016 this approach has worked for Trump in the Iowa and New Hampshire primaries, stalling progress by rival Ted Cruz, and holding back other rivals. Yet this approach has its risks as the primary season progresses. One of the changes in the Republican party politics in 2016 is the emergence of two candidates Donald Trump representing the white working class, and Ted Cruz representing evangelicals, who are both strident and willing to take strong positions on issues in striking contrast to leading Democrats. Trump on China, immigration, refugees, and Cruz on taxes, cultural issues for evangelicals, IRS, Affordable Health Care Act, and both candidates on terrorism. ...

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Angie's List provides information on home improvement contractors and on health care companies. It was started by Angie Hicks after she graduated from Depauw University in Greencastle, Indiana. It has 400 employees and is based in Indianapolis. Sales reached $60 million in 2010, with revenues from membership fees and select advertising by highly rated service providers. It started with Mr Oesterle, a former boss of Angie's in a college internship, and his moving to Columbus, Ohio. Oestlerle had difficulty finding good contractors to renovate a 1920's home, and suggested they work together on this idea of a list of reliable contractors based on personal interviews. The company still relies only on personally obtained information.

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From now on the vaccination program in India will be run nationally by the federal government. This will ensure fair access to vaccines to all parts of the Indian population. Earlier vaccine costs were bid up as states and private hospitals bid up prices. Under the new national program 75% of vaccines will be given out by the federal government and 25%  by private hospitals and other private health institutions. The government in New Delhi under prime minister Modi will offer adults free vaccinations. Modi said "We will increase the speed of procuring vaccines and also increase the pace of the vaccination program." Even in private hospitals the cost of vaccine will be kept at Rupees 150 or $2.06. Experts say this is the right policy and the government has learned from errors in letting states and other private institutions run vaccine policy, which made it too fragmented and subject to too many variables, resulting in inequity, and slowing vaccination drives. The Supreme Court stepped in asking for clarity, leading to the clear policy from the federal government announced today.  Advantage of the new policy is that the responsibility lies in one place, and the federal government also has the clout to make things happen, to negotiate with companies and other parties involved effectively. India has vaccinated 222 million people but because of the population being so large at 1.2 billion this comes out to be a small fraction of the population. This puts the task of getting vaccine supplies and getting the vaccination drives to work in the only place that has the determination and the resources to deliver results by vaccinating 1.2 billion people by December 2021. It has never been done before in history says Mr. Modi, and it is a challenge that India is now taking up for itself and for the global community. It also lays the ground for India to help its neighbors in Asia and in Africa, Latin America in 2022.   ...

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Many of the achievements of Jindal in the areas of education, and competitiveness and health care and infrastructure for the state of Louisiana are now at risk because of an anticipated deficit of $2 billion in state revenues for 2009 and in the current year the $865 million surplus has evaporated and turned into a$365 million shortfall all in a short time. The state budget used afigure of $84 abarrrel for oil in calculating the state's revenues related to oil revenues generated in the state from offshore drilling but with oil at $40 a barrel things are not lookin good. The total intake from oil and gas from royalties and leases accounts for 17% of the Louisiana state budget. The state rolled back atax increase and increased expenditures on much needed higher education and health care and infrastructure spending. Louisiana needed these programs because it continues to lose people to migration and is the only southern state to do so. The expected cuts are $109 for education and an additional $160 million for health care cuts much from Medicaid. It also shows how quickly things can change for states that are overdependent on natural resource revenues and in this deep downturn for a range of states from California, to New York to Louisiana....

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With the strong jobs growth report in September the US Federal Reserve, America's central bank, is expected to increase interest rates by 0.75% at its meeting on Nov. 1-2. That will be the fourth interest rate increase in 4 consecutive meetings of the Fed. It is designed to tackle inflation yet it also reverses the period of low interest rates for savers that extended from 2000 to 2020. This period covered two crises one created by irresponsible behaviour of banks in the financial crisis of 2000 and the second a natural health disaster from the pandemic when interest rates were brought down to zero as a policy response. During that period savers who suffered decline in savings with little interest income and lower income groups were hit by both the financial crises, employment gaps that hurt income and savings, and the shift of jobs overseas as jobs were shifted to China and American manufacturing declined. Economic policy was determined in that period by economists who failed to grasp the dangers to American manufacturing, to American communities with loss of jobs from offshoring, rising inequality that fragmented society.   This has changed under the Fed run by Mr. Powell first appointed by Mr. Trump and now renominated by Mr. Trump, who is not an economist and brings a very different mindset to central banking, going with common sense about what works for average Americans. a sense of humility, and down to earth about American workers and American manufacturing and its place in America. ...

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Wuhan has announced  only 3 new confirmed cases since March 18. Restrictions on travel were lifted after a 77 day lockdown on the city, allowing inbound and outbound travel. Some restrictions on housing complexes have been tightened after reports of dozens of asymptomatic cases. The number of asymptomatic cases remains unknown. There is a fear of a second outbreak and authorites are staying vigilant, as it is feared that the first outbreak was worse than previously thought. Epidemiologists, intelligence agencies, and health experts believe the number of cases reported in Wuhan and China are undercounted. This could be they say a result of local officials wanting to present a better picture, of not enough testing in the early stages, not counting people who died at home, and including people who died of pneumonia under pneumonia instead of coronavirus. Dr Birx, head of the U.S. response effort,  says the U.S. lists people who died of pneumonia in New York as coronavirus deaths because of how widespread it is there, hitting seven people in a thousand. In addition there is a problem for all countries in counting people without symptoms. No one even knows how big that is, and Dr Birx in the U.S. says it is important to find out. ...

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Galston says Hillary Clinton is right to say as she did at Roosevelt Island in her opening campaign speech, that "growth and fairness go together, for lasting prosperity, you can't have one without the other." Economic growth was at 4% for 5 of 8 years of the Clinton presidency, but in the 15 years since the economy has managed 3% only twice in the George Bush presidency, and fallen below 2.5% in the last 5 years. The high growth rate following World War II was a result of the increase in the workforce and productivity. The workforce increased by 2% annually between 1950 and 2000. Since then as female participation peaked and the baby boomers reached retirement age the workforce has increased by 0.7%, and is slowing to 0.5% annual growth for the next decade. Growth in productivity of 1.9% between 1991 and 2007, slowed to 0.4% after 2010. Galston tells the next president to go all out to increase the labor force- adopt family friendly policies similiar to Europe so more women can work, get more immigrants into the labor force, more elderly should be encouraged to work given the better health, reduce the college dropout rate to reduce incarceration and bring more young people into the labor force, get more people who qualify for disability but could work part time into the labor force, and emphasize the importance of increasing the labor force participation rate a policy being followed by the Federal Reserve's Janet Yellen....

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Fitch Ratings analyst Charlene Chu tracks unreported debt in China's shadow banking system. She is doing this after moving to China in 2004, following work at the New York Fed. She was first alerted to the increase in unreported private debt when a banker disclosed to her at a meeting that he was pushing loans off the bank's books by repackaging it as securities and calling it wealth management products. She sees shadow lending in the banking system as a way to extend credit beyond the bank's government quota and not disclose questionable loans. The growth in private debt is alarming, much of it unreported. China undercounted private debt by 28% or 1.3 trillion yuan ($212 billon ) in the first half of 2010. In July 2011, the People's Bank of China added many of this type of off-balance sheet type of lending to its figures, following Chu's example. Her figures are still higher and she says conservative estimates. Fitch Ratings puts China's private sector debt at 214% of China's GDP as of June 2013, from 129% in 2008.The central bank's estimate is about 20% lower. Shadow lending soared after China increased lending in 2009 as part of the Stimulus policies. ...

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Amy Chozick of the NYT describes the puzzling idea of a Methodist do-gooder, with serious concern for injustices in the South, making an effort to accumulate money. Especially considering that Hillary Clinton must have known that speechmaking fees would come up in a presidential election campaign. Chozick describes in some detail the two years Hillary tried to shore up the family's finances after Bill Clinton's defeat in the 1980 election for Governor. Following the defeat Bill Clinton went back all over the state to voters to hear their complaints, sometimes for hours at a time. It was upto Hillary to shore up the family's finances. Hillary had to stretch to buy a $112,000 home in a better residential neighborhood. Family friends say Bill was never that interested in money, and never worried about the family's finances. Things were so bleak according to this account that Hillary worried about how they would pay for daughter Chelsea's college tution, as her own mother's experience has always remained with her of being denied a college education because of lack of money. During the Democratic Convention this comes up in the video introduction, something that most people are unaware of, which must have been difficult for an intensely private person like Hillary. Her mother is described in that video as having to go to the corner grocery store as a child with coupons for food. The income of the Clintons as professors in the years around 1975 was $18,000 each. As governor Mr. Clinton earned $33,519 in 1978 with combined income at $51,173 adding Hillary's work at the Rose law firm. A one time deal in the commodities market made 100,000, and an investment in land in the Ozarks led to losses- all at a time when other highly educated people in Arkansas were doing extremely well, including the Walton family. It wasn't until 1992 when Bill Clinton was running for president did the couple make higher income of $297,177 reported in 1992 tax returns. At this time entering the White House, of recent presidents only Harry Truman had lower net worth. Hillary donated her book proceeds for "It Takes a Village," to charity, and turned down an advance. By the time they left office the couple were faced with legal debts, owing $5 million in legal fees- Hillary Clinton saying they were "Dead broke." The former president now sought help to buy a Dutch Colonial in Chappaqua, New York, for $1.7 million. President Jimmy Carter was also facing large losses in his peanut business in Georgia when he left office, only to turn to writing books to salvage his finances. Hoover, FDR, Kennedy, George Bush, George W. Bush, were from families with great wealth or built their fortunes, including candidate Trump, sometimes using influence or connections or in the case of Kennedy's family gaining from the end of Prohibition. Eisenhower, Reagan, Carter were of more modest wealth. Only Harry Truman remains the awesome exception of dignity with extremely modest wealth, a small house in Independence, Missouri, no presidential pension, only an army pension of $112.56 a month in 1953. Truman's story also offers another aspect of public service of an exceptional kind and its value to the country for people to reflect on. A presidential pension of $25,000 was set up one year after Truman left office.  Experts say Truman's Senate Committee over 8 years 1941-1948, helped save billions of dollars in waste, fraud, and in faulty airplane as well as munitions development during the war effort, including saving thousands of lives.  In his farewell address in January 1953, Truman said he had spent 17 hours a day for eight years with no payment for overtime. In the address he correctly predicts that the Cold War would be won and he set the course. It also happened as predicted in that address with changes in the Kremlin and failure in the satellite states. Hillary Clinton put in these 17 hours and gained unmatched experience as Secretary of State, and is in a positon to set the course ahead in a manner that Truman once did in a complex world where careful policy, good judgement and in some situations strong action is needed. Such invaluable public service has never really been rewarded in the way business leaders are, not by a small fraction - too long simply taken for granted.  Considering her life story Hillary Clinton appears to have struggled with this all her life, to create a safety net that too often cracked, sometimes suddenly and unexpectedly. Has this concern sometimes gone too far, could better judgement be exercized. Perhaps or probably. Should it be seen in the context that Truman's situation reminds us. Probably.         ...

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Speaker Mike Johnson says democracy is "messy," as Rep. Greene of Georgia calls for a resolution for him to step down for violating a rule that no legislation would be brought up that lacks majority support. Only 101 Republican members of the House supported it less than half. How then would the funding of the federal government its departments of defense, homeland security, education, health, operate as the deadline for funding it is tonight? This is left unsaid. One can see the Senate and House live on C-SPAN television at this very moment. It appears that the older senior members of the Republican party have not done a good job of talking to their younger less experienced colleagues and building agreement, that the mediocrity of leadership in both parties for the past three decades, even four, is the cause. Unstable politics in the Republican party as it is split with older senior members on  one side and younger many first time elected organized by the Freedom Caucus group on the other.  Many are from the Southern states and some from rustbelt midwest showing the deep divides that still shape the US. Democrat Steny Hoyer the House Minority leader who has worked in Congress for over 40 years called it on the House floor, and he said its a harsh word delaying and "dissemble." Democrats call for compromise to govern, the compromise was finally reached today March 22 to pass the $1.2 trillion spending bill with something for each side or somethings that both sides wanted, funding at border and child care. ...

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Under the law overturned by the US Supreme Court it was illegal to carry a gun openly and a permit was needed in New York to carry it concealed. Three Supreme Court Justices appointed by president Trump were of a disposition that opposed gun control laws- Gorsuch, Kavanaugh, and Barrett. The requirement under the New York law was that you had to show "good moral character" and "cause" to carry a concealed weapon or carry a gun openly. Many other states have such laws in California, Hawaii and urban states in the north east. Republican states are loosening gun control laws. This comes as many random shooting incidents are taking place in the US some in schools and grocery stores, the most recent being a shooting in Buffalo, NY. The vote was 6-3 after the Supreme Court for years had avoided hearing such cases based on Second Amendment rights from the Constitution that some had interpreted to include freely carrying guns without any common sense restrictions. This issue is second only to abortion as a cultural issue in the US on which sides are taken by the public including the Supreme Court Justices selected by Mr. Trump. Though not directly apparent these and issues of immigration, other cultural issues surrounding gay rights are putting those who would normally come together on issues of national interest on opposite sides when it comes to common sense support for everyday issues of feeding families, keeping workers employed in good factories at home, child care, education, health care, fair wages, restoring America's manufacturing leadership and bringing back manufacturing to the US. The emergence of Tech and tech companies, Silicon Valley, the finance sector in New York, has reinforced the prejudice in these opposing sides as Tech and the finance sector have largely embedded themselves into the Democratic side. Tech and finance sector employees with higher incomes have largely insulated themselves from the interests of ordinary workers and families creating a split Democratic party when it comes to supporting workers and families who form the vast majority of the American people. In a sense today the national interest is separate from these cultural issues and supporters of national interests can be found in both parties who can look beyond and above these cultural issues. It is also where many of these cultural issues can be resolved to some degree using common sense on which most informed members of Congress can agree. This is true for gun control as a group of bipartisan Senators from both parties are preparing gun control around common sense principles that today are even beyond the capacity of the Supreme Court of the US that itself now reflects a raucous public sphere. ...

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David Axelrod affirms the President's firm moral tone. The budget document in the President's letter forcefully attacks " a legacy of misplaced priorities and irresponsible policy choices in Washington". It confronts the "growing imbalance of accumulating wealth and closing doors to the middle class." The letter says "we must usher in a new era of responsibility and begin the hard work of bringing new levels of honesty and fairness to your government." Axelrod's view is that the tone says what Americans and the President have realized for some time now, that its institutions both government and private have let America down.

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The NYT's Kristof gives this exceptional report on the use of cancer causing chemicals all around us in many consumer products. With the increased use of chemicals has come the tripling of asthma rates in the last 25 years, leukemia up by 1% a year, increasing obesity, and breast cancer rates increasing from 1% in 1975 to 12% today with only some of it from better detection. Doctors at the Mt. Sinai School of Medicine in New York, say American girls who had puberty at the age of 17 in 1800, now have puberty at the age of 14, even 12. Earlier menstrual cycles increase the risk of breast cancer because of increased exposure to estrogen. Studies show exposure to pesticides, PCB's and other cancer causing chemicals increase the risk of cancer, and a link to early puberty. Asian women moving to the U.S. are also experiencing higher rates of breast cancer as they move to societies with higher use of chemicals in daily life, say experts at Mt. Sinai. Poor eating habits and lifestyles with less exercize are also to blame, but chemicals also play a role. Americans are moving towards shunning packaged processed foods for fresh food in their diet, and more are learning the benefits of regular exercize, but the same degree of public awareness is lacking for the extensive use of chemicals in our consumer society. In other societies around the world that are copying us such as in China, India and Brazil, the situation is even worse, with the spread of a reckless idea that modernization requires jettisoning health safety concerns. Even a simple pizza box has PFAC's chemicals made to make the box resistant to grease. In 2015 where products are labeled environmentally friendly by large companies to attract buyers and build the right image in the minds of consumers, consumers asking questions and making better choices make a difference by offering a seal of approval. Carpets have chemicals, and most disposable plastic containers contain chemicals that could seep into the food if heated. The use of plastic containers and microwaves is common practice in todays society, where less cooking is done on the stove than in the period before 1960. The sheer size of the chemicals developed since 1950 is staggering- more than 80,000 chemicals according to the Children's Environmental Health Center at Mt. Sinai. And this Center says less than 20% have been tested for toxicity. ...

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From the country of "Feierabend" the much appreciated German term for cutting off the workday to do something else like biking or running which is very healthy way of living during the pandemic and everyday, come more German expressions which tell us  more about how to live.  "Na Wie Lauft's" is the German expression most people learn because it means "how are you running", and shows people you care about them. Here DW.com, looks at other German expressions with wonderful pictures of people and scenery in Germany to accompany each expression that has a soothing, calming effect on all. The meanings are given by DW.com, the German national broadcaster which also helps people learn German. "Die Dinge Laufen Lassen," is another German expression that has a Zen nature and is one that one take comfort in for its calming effect. It means "let things run their course, and everything will be alright in the end." "Noch in den Kinderschuhen stecken It means things are only in the early stages, beginning to develop, unfold, the ball is only beginning to roll. With it goes "Laufen Learnen" which means you have to walk before you can run. "Lugen Haben Kurze Beine" means "Lies have short legs." It suggests walking or running. It says you won't get far with lying, you won't get ahead with it, somebody will see through you. "Auf dem Ruder laufen" means to lose control of an oar while rowing a boat to stay on course. It also means hang tight and things will right themselves eventually. And to go with this is the German expression about learning the procedure or techniques for getting the work whatever it is done correctly. Wie est der Ablauf" how will things run, what is the procedure for doing it? Positive expressions from the images of running or walking at the time of the pandemic when this can have a soothing and calming effect.   ...

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What were the stories in the Economist magazine that were the most read stories of 2019? Not on president Trump. On Malaysia, China under Jinping, and exodus from San Francisco and Silicon Valley. The most read article was on the newly elected president of Brazil, Jair Bolsonaro. The mismanagement of the economy particularly extravagant state spending on the Olympics and soccer stadiums for the World Cup at the expense of basic sanitation services, bus and transport services, health services, led to the result of a majority of Brazilians rejecting the Workers Party and its leader former president Lula. Unfortunately most of the media including the Economist did not draw attention to this gap. During a period in which income from mining with export of iron ore, and soyabeans to China, enabled Brazil to live beyond its means, there was no effort to draw attention to glaring gaps in development of public services such as sanitation, bus services and transport, lack of building infrastructure other than to support mining. Glaring gaps in education and health services made the situation worse. The second most read piece in the Economist  was on March 10th- Malaysia's PM is about to steal an election. Here the Economist magazine joined the Wall Street Journal which originally broke the story on the 1MDB fund and irregularities in Malaysia where a development fund was misused by the government. Najib actually lost that election and the WSJ covered the story of the developments that followed in which Malaysia's new governemnt led by a returning former prime minister in his nineties Mahathir Mohammed, ousted his own protege Mr. Najib.  The third most read piece in the Economist magazine was - How the West got China Wrong.  Unfortunately the Economist magazine and most of the media covered China in the two decade long boom years without covering the other emerging story as well in which Mr. Lighthizer (now president Trump's top trade adviser) and others questioned the huge unsustainable trade surpluses in U.S. trade with China. With the economy facing huge downside risks and rising trade tensions with the U.S. Chinese president Jinping's move to remove the limit on terms in office in the Constitution was considered a shift from the notion that China was likely to turn into a democracy. Mr. Jinping had already completed his first term in office and the anti-corruption campaign, managing the economic boom for a soft landing, was carried out with the central leadership of the party, after the destabilization evident in the early part of Xi Jinping's first term. Much of China's path was predictable and rational behaviour in its national interest, what was not clearly defined or defended was the way the U.S. could sustain the trade deficits that had reached a billion dollars a day. Leading to Mr. Trump seizing on this as an election issue to form a bloc of voters separate from the two main parties, the Republicans and the Democrats. The fifth most read piece was on Oct 11, 2018- the next recession. It pointed out that with low interest rates central banks in the U.S. and Europe and America could not cope effectively with a recession. The sixth most read piece was on June 29, 2018- Bullshit jobs and the yoke of managerial feudalism. It cited Prof. David Graeber of the London School of Economics, who wrote a short essay that went viral on the prevalence of work that had no social or economic reason to exist, work he called "bullshit jobs". Graeber said people want to feel they are transforming the world around them in a way that is leading to a positive difference. No. 7, 8, 9, were on Bitcoin, Netflix and programming language Python. No. 10 most read was on Aug. 30, 2018- Why startups are leaving Silicon Valley. It showed that in 2017 more people left the county of San Francisco than entered. The main reason the cost of living was burdensome and out of control. As Amazon shifts attention to India and Brazil, and Apple pulls back from India, social media companies coming under fire for disinformation, this period of Tech is making way for a shift in a new direction. A direction that focuses on people's lives, wages, spending on much needed infrastructure and services. ...

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We show here several articles from The Guardian on the topic of family time. Keir Starmer said he would keep Friday nights after 6 pm for family time. His wife Vic Starmer 50 years, works in occiupational health at the NHS and wants to continue her life as usual unaffected by Labour's and her husband's win. The couple wanted to stay at their north London home and not move to 10 Downing Street as the two value their privacy highly. One of the children is taking the GCSE's and the wish is for the family to keep going on as normal. Starmer says he also get a direct insight into the NHS from Vic Starmer's interaction with the NHS staff.

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CEO Ryan at CVS/Caremark. An unassuming man with a sharp focus on things, joined CVS right out of pharmacy school at University of Rhode Island. At 29, CVS owner Stan Goldstein gave him the chance to run pharmacy operations for CVS, then a regional drugstore chain in the eastern USA. Over the years CVS has made a number of successful acquisitions, the latest being the acquisition of Longs Drug store chain on the west coast, and it is now one of the largest chains in the USA. It has nearly 7000 stores and more than 50 million users of its CVS loyalty card in the US. As the pharmaceutical business evolved pharmacy benefit management (PBM's) companies like Caremark, Medco, and Express Scripts, came into being to manage burgeoning prescription costs. PBM's work with companies to save money, by filling recurring prescriptionsin 90 day quantities through the mail at reduced per pill cost. Now drug store chains instead of competing with PBM's are either creating or acquiring these larger PBM's. THe result is that a company like CVS which acquired PBM Caremark in 2007 for $27 billion, now has extensive computerized databases with patients information and drug usage histories. Ryan's clear focus is on these IT records as a distinct advantage, if he can use it to help the Obama administration's efforts to control health costs of chronic diseases like diabetes and arthritis, and back or neck pain, high blood pressure, and others, that end up clogging the hospital system and raising health care costs. By using these IT records to flag when a patient is not compliant or taking his medications and call the patient, Ryan can increase drug sales, get more visits into drugstores if the drugs can also be picked up at CVS stores, and increase sales through ancillary purchases during visits. This is now his strategy. It also includes setting up more clinics at stores and at corporate locations that divert the patient flow for small care like sore throats, flu and the like. As this is the way health care costs can be controlled, Ryan sees himself as helping achieve national goals while keeping CVS in the sales and profit picture for the US, even as health care as we know it goes through a complete transformation that removes the waste and unnecessary cost, and improves effectiveness and health. He sees CVS/Caremark right where it wants to be with its large patient drug database from about 1 billion prescriptions it fills each year, and as the largest single buyer and dispenser of prescription drugs in the country. ...

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Donald Trump is acquitted in the second impeachment trial with a vote in the Senate of 53 in favor to 47 against. A two thirds majority is required to impeach a president. Senators Burr of North Carolina and Cassidy of Louisiana were Republicans who joined the expected ones to vote for impeachment- the Republicans Mitt Romney of Utah, Pat Toomey of Pennsylvania, Ben Sasse of Nebraska, Susan Collins of Maine, Lisa Murkowski of Alaska. The Republican defense lawyer insisted that Trump's speech to his supporters was not an intention to incite them on the day of the Capitol riot on Jan. 6, 2021 but an expression of his rights to free speech guaranteed under the U.S. Constitution First Amendment. He made the point that the prosecution lawyers had selectively focused attention on the words "fight like hell" and taken them out of the entire context in which they were made, ignoring key parts of Mr. Trump's speech. The defense argued that the president had already left office and this made an impeachment unconstitutional. Seventy five million voters voted for Mr. Trump and he cited this as the most number of votes won by a sitting president. President Biden is shifting his attention to the president's agenda and needs Republican support to pass key legislation including financial help to households, unemployed, and business to recover from the pandemic. The U.S. health effort behind the vaccination drive and seeing the struggle in Europe to access key medical supplies of vaccine is also leading to new efforts to move beyond the rhetoric to the hard work ahead with support of all parties. As part of this the trial once it reached the Senate was quickly resolved in about 5 days. The defense used only a small fraction of the time allotted with bipartisan effort to not let the trial drag on, bipartisan effort to putting some statements simply on the record and not calling witnesses.   ...

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As the pandemic continues to spread and numbers grow with reopening of the economy the question remains -what can we learn from other countries positive experience in controlling spread? Here the Times provides the example of German contact tracing- chancellor Merkel has emphasized that a lot depends on "total" contact tracing, and contact tracing "above all else." Germany's experience is that even if you don't get everything right, you make an honest effort with everything you've got and do it early it makes a real difference. Some of the offices across Germany are stretched and short of staff but they have been working since the beginning of March, sometimes in the early days 7 days a week. Only 33% or one third of the offices throughout Germany for contact tracing have the required 5 person team for every 20,000 people, and 35% are overstretched or at their limit, according to one survey. No apps, just a low tech effort with people from the state administrations who were not working during lockdown trying doing something else, or volunteers. Mainly using the phone, talking to people and tracing the contact chain of people testing positive. Putting this information on the computer with a central database.  The Berlin office has 115 workers and has tracked down every one of 666 virus cases it was given. Because of privacy concerns at the Munich office sometimes even the patient's name is not given and office staff have to locate the name and the person. It requires dedication, flexibility and above all resilience, says Harold Rau, the deputy Mayor of the Cologne office, cited in this Times report. The doctor alerts the local office with a test result. The office calls the person and finds out who he has been in contact with for the last 14 days. Then the people who were in contact with are grouped based on the directness of contact, face to face, so on. These people are asked to quarantine for 14 days, sometimes with the rest of their household. They get daily call to find out how their doing for symptoms. The effort goes back to Robert Koch in the 1892 cholera epidemic in Hamburg. Robert Koch, microbe hunter in Germany, was called in after the epidemic spread from Moscow. It devastated Moscow and Tokyo, but Hamburg suffered far less about 8605 deaths as a result of the contact tracing and strict closing off quarantining of affected chains after isolating them, closing off affected parts of the city. Bit by bit the cholera epidemics sparks were put out before turning into flames, says Koch. In the current pandemic Germany has suffered 8241 deaths and 178,000 confirmed cases. So far this is in line with the cholera epidemic in Hamburg 1892, and this for all of Germany. And it is not just affluent nations that can do this. where there is a will there is a way. In Kerala state in southwestern India, similar efforts have worked to limit spread  with even better results than Germany. ...

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Low bank wages for the U.S.'s 500,000 bank tellers. The median annual income of a bank teller in the U.S. is about $24,100 or $11.59 an hour, according to the Bureau of Labor Statistics. According to a report by the Committee for Better Banks, about 39% of bank tellers in New York rely on public assistance. Nationally bank tellers need $105 million in food stamps, $250 million in earned income tax credit and $534 million in Medicaid and Children's Health Insurance Program to get by. According to SNL Financial bank profits reached $141.3 billion in 2012, and median chief executive pay was about $552 million.

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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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This editorial in the WSJ describes the sharp increase in premiums under the Affordable Care Act of president Obama. The average premium increase is about 24.2% according to a Barclay's analysis, and as high as 43.9% in states such as Illinois. Bill Clinton calls it the craziest thing with small business affected, and some premiums doubling. Of the 17 million people in the individual market eight million buy without subsidies. One in five enrollees cannot qualify for subsidies. Democrats say subsidies are too small. Hillary Clinton has proposed to have a Medicare "buy-in" for people ages 55-65, and a "public option" government run plan. Republicans want to rewrite the law. But this depends on which party wins the Senate, with the election in Missouri giving Democrats an opportunity to maintain a Senate majority.

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Justice Ruth Bader Ginsberg, the oldest person on the U.S. Supreme Court dies at 87. The U.S. Supreme Court is unique in that there is no retirement age as in India and other countries. She died of pancreatic cancer. She is one of the rare jurists in that she continued to work almost to the end. She was unique in other ways because she got along well with colleagues on the court of different persuasion. Justice Scalia who was the complete opposite in thinking and views than Ginsburg said that this did not matter much as Ginsburg was "fun to be with." Former president Clinton nominated Ginsburg in 1993. Recently Justices Gorsuch and Kavanaugh joined Roberts, Alito, and Thomas,  for a 5-4 majority on the court for conservatives. Ginsburg was a woman's rights advocate in the 1970's. She will be missed mostly for her vigorous personality and feisty attitude to life working and being active even with her health condition. The death of Ginsburg means that the court is now deadlocked with 4 to 4 and no majority for conservatives or liberals. The country has also changed. Both conservatives and liberals claim they uphold the constitution of the country. Ginsburg saw this as the inclusiveness the founders intended- for women, and minorities. The conservatives see this also from the vantage of inclusiveness as the country has splintered into those who are largely college educated and tech savy, and the high school educated and less tech savy more rural and in small town that lost jobs and social services from the shift of manufacturing to China. The conservatives  see the lack of inclusiveness for the rural communities and small towns left out in the tech booms of the last three decades and shift of manufacturing overseas. Cultural attitudes add another layer to basic economic issues and a sense of alienation on both sides. In this climate and with an approaching election in 41 days the Republicans want to nominate their conservative choice supported by their Senate majority, and the Democrats want to block this appointment till after the election.   ...