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Clarence Cammers, 64, one of Paul Ryan's constituents back home in Wisconsin, has a question for Ryan at one of his townhall meetings. Clarence is worried about what would happen to his son Tim, 32, if Medicare cuts went through and his son had to use vouchers for getting health insurance. Ryan's district includes Racine withe high unemployment, and Janesville which was devastated by the closing of the General Motors plant in 2010. Most of the people there are conservative, believe in fiscal responsibility and a balanced budget, but they are also older, working class people. Some of them like Clarence are dependent on their Social Security check to get by from month to month and are not sure they can cope with the kinds of cuts Ryan is proposing. In this story Clarence and Tim discuss the meeting and come to the conclusion that Tim will lose either way- with taxes going up or Tim not getting the retirement that he should be getting. Clarence a life long saver decides he will cut back on his expenses and save $588 from his $1912 monthly social security check for Tim. Tim has severe attention deficit disorder and works for $10 an hour in food prep at a resort....

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The major provisions of the Republican House healthcare bill that passed by a vote of 217-213 are- 1. To help people buy insurance coverage the bill offers $2000 to $4000 a year, upto $14,000 a year in credits based mainly on age, reducing them for families making $150,000, individuals making $75,000. 2.  Under the Affordable Care Act insurers cannot charge older Americans more than 3 times for same coverage they offer to younger people, the new bill makes this 5 times. This would increase premiums for older Americans and reduce it for younger Americans. This is the most controversial part of the bill. Older Americans supported the Republican party in the presidential election. 3. The new bill ends Medicaid as an open ended entitlement and places this on a budget with cuts of $880 billion over 10 years. 4. To mollify conservative Republicans a provision allows state to opt out some provisions of the ACA that requires minimum benefits such as maternity care and emergency services. It retains coverage for pre-existing conditions to mollify moderate Republicans. The bill provides states with $138 billion over 10 years to subsidize premiums, provide coverage for pre-existing conditions, mental healthcare and drug addiction. 5. The bill removes the taxes imposed under the Affordable Care Act (ACA) on high income people of about $300 billion over 10 years by repealing a payroll tax increase and tax on investment income. This bill and the ACA offer 2 competing visions on healthcare, both bills passed only by a margin of 4-5 votes in the House. The ACA overlooked the impact on premiums causing discontent among middle income Americans. The new bill lets premiums rise for older Americans in order to keep premiums down for other Americans. This shows the many tradeoffs involved and choices being made, and the lack of a consensus on the issue of healthcare in the U.S., becoming a highly politicized issue instead of the way it is treated in western Europe.     ...

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Prime minister Johnson of Britain blames his coronavirus on being overweight. He can now be seen playing tennis at Winfield House, the residence of the American Ambassador. He can also be seen in the Queen's Lambeth Gardens taking a run. Both have been offered to him for use after the prime minister ran into someone at St. James Park. Boris Johnson now says as  word of advice to many middle aged people "Don't be a fatty in your fifties." Take up exercize he says to a generation of men that have just become lazy when it comes to exercize. Other things to be stronger with the virus are healthy eating habits, lots of ancient grains, lentils, fruits and vegetables. Add  yoga, meditation, call it mindfulness if you like, it works, and it is never too late. 

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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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Azimji Premji of Wipro is one of the few Indian business leaders with a strong bonding with Gandhi's ideas of personal responsibility for India's betterment and the betterment of millions of ordinary people in India. He says Gandhi influenced him only next to his mother who ran an orthopaedic hospital for disabled children for 50 years, and learned what it took to do this as well as the difference it made in people's lives. He quotes Gandhi as his own personal philosophy-  "Supposing I have come by a fair amount of wealth- either by way of legacy, or by means of trade and industry- I must know that all that wealth does not belong to me; what belongs to me is the right to an honorable livelihood, no better than that enjoyed by millions of others,. The rest of my wealth belongs to the community and must be used for the welfare of the community." Azimji Premji gives as three enduring parts of Gandhi's leadership- the pursuit of truth, the importance of means over ends, and empathy for all human beings. He cites a saying of Gandhi to be seen at Sabarmati Ashram and Gandhi Smriti- "I will give you a talisman. Whenever you are in doubt or when the self becomes too much with you, apply the following test. Recall the face of the poorest and the weakest man (woman) whom you may have seen, and ask yourself of the step you contemplate is going tobe of any use to him or her. Will he or she gain anything by it? Will it restore him (her) to control over his (her) own life and destiny? In other words will it lead to swaraj for the hungry and spiritually starving millions? Then you will find your doubts and your self melt away." ...

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David Brooks of the NYT describes the approach taken by British prime minister David Cameron and his Conservative Party government to help the working class poor in Britain, and tackle the social roots of poverty. He says an American adaptation similar to this is badly needed in the Republican Party, with the candidates in the election providing solutions from an old rulebook. Only after Trump's popularity with appeals to less educated older Americans has the Republican leadership responded, with Speaker Ryan helping organize a forum on poverty under the Jack Kemp Foundation- emphasis was placed on education, work, opportunity and accountability for anti-poverty programs in the discussion moderated by Ryan and Senator Tim Scott. Less attention was paid to the other social aspects mentioned here by Brooks, and cited by Cameron when he described the inadequacy of traditional solutions from the right and left of the political spectrum. Cameron outlined the principles of his anti-poverty plans called "Life Chances Strategy," in a speech on Jan. 11, 2016, in north London, with the entrie transcript on the gov.uk website. Cameron acknowledged in the speech that social issues including single parent families, and other social problems such as long term unemployment, can make it harder for some people to use self-reliance and personal responsibility in a growing economy as a way to grasp opportunities. Cameron proposes a combination of economic, social and job growth strategies. His second term plans include 30 hours a week of free childcare for 3 and 4 year olds so both parents can work, parental maternity leave, expansion of Troubled Families Program, in addition to the introduction of National Living Wage, tax cuts, universal credit. In tackling social aspects of the problem Cameron cited the need for development in the early years of childhood, the huge importance of family, social connections and experiences, informal mentors, cultural experiences, broadenend horizons, that enable young people to acquire language skills, character and resilience. Second term projects include expanding reach of high performing schools to deprived areas, emphasis on core English, math, science, history, geography Ebacc skills, a 1 billion pound investment in the National Citizens Service by 2021, a plan to transform housing estates including rebuilding from scratch, additional 1 billion pounds to provide mental health treatment including treatment within 2 weeks in homes and communities. Throughout Cameron's "Life Chances strategy" is aimed at tackling not just the material dimensions of poverty, but also what he describes is broken in Britain- "the paucity of opportunity."...

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The Economist magazine says Mr. Trump's claim that he could fix things because he is an outsider is now quickly proving to be false. The lack of experience works against the Trump administration as it stumbles from one crisis to another. The tweets that were used to turn voter sentiment against opponents now work the other way. There are other problems that are noted here but not emphasized to the extent they need to be. Mr. Trump, as Peggy Noonan, a Reagan aide, has pointed out in the WSJ, risks alienating the very blue collar vote, and older voters whose interests he claimed to defend. This happened with the Ryan Republican House health care bill as millions of poor Americans approaching retirement were one of the worst affected groups. The Economist points out that the next project to tackle tax reform has the same possible consequences for the Trump blue collar base, as it says Republican plans for tax reform are seen as regressive. Tax reform has eluded previous administrations, and requires more experience in building coalitions which the Trump administration lacks in its confrontational attitude towards Congressmen on both sides of the aisle who disagree with him. Improving the U.S. trade position, infrastructure investment are other areas that the administration plans to tackle, yet the first 100 days show that the lack of experience and the lack of a calm composed mind is hurting the Trump administration, to the point of policies that hurt the very voters who put their faith in the Trump administration to improve things. A similar process is unfolding in Britain as it faces a Brexit negotiation that the Economist points out has been badly handled by prime minister Theresa May, and could lead to worsening the economy if no deal is reached because the European Union sees that it is not in its interest to do so, and Ms. May realizes only later that she has taken nationalist sentiment a bit too far for a European economic arrangement to work and provide mutual benefit. A continent wide economic arrangement that it was the wisdom of past leaders from Britain, France and Germany to support for over six decades is not easily undone by one vote, or one government. ...

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Allan Blinder gives a spirited account of what he sees in the Paul Ryan Republican deficit reduction plan. He says that with the voucher plan retirees would fall further and further behind the increasing cost of health insurance. With no explicit cost containment proposals it assumes that some kind of miracle will occur for costs to be kept in check- especially as Republicans want to repeal the cost containment proposals in the President's healthcare plan. He asks whether someone is saying, that we have to destroy Medicare so it can be saved. Ryan woulld also turn Medicaid into a block grant, then underfund it and let the states figure it out when they are in a budget squeeze. Blinder points to the estimates of the Center on Budget and Policy Priorities, that show about two-thirds of Ryan's budget cuts would come from programs that serve low and moderate income Americans. And to make matters worse the steep spending cuts go to finance tax cuts that largely benefit the wealthy. He calls this Robin Hood operating in reverse, and coming on top of 30 plus years of rising inequality. David Stockman makes a similiar point on the editorial pages of the New York Times, April 24, 2011; also adding the point that the middle class will have to pay higher taxes for the deficit to be addressed, something President Obama's plan fails to do. Blinder says that the Bowles-Simpson and Rivlin -Domenici proposals attack the deficit reduction problem in a better way, that asks something from all classes and interests. ...

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This NYT editorial points out that the cuts to Medicaid amount to taking out a fourth of its budget and are sure to hurt low income Americans. The cuts are about $880 billion over 10 years for Medicaid. The $300 billion less in subsidies over ten years is likely to hurt the elderly. It also points out that removing the individual mandate will make it harder to reduce premiums as fewer healthy adults offset the costs of sick patients.

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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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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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Gerald Seib of the WSJ points out that the winners in the passing of the Republican healthcare bill in the House by a 4 vote margin are Speaker Ryan who never wanted the job in the first place, and president Trump who showed he could cajole Republicans into getting it passed because he likes winning. Now comes the hard part says Seib, when it goes to the Senate- House conservatives are not going to be happy when they find major changes they dislike. If the bill clears the Senate in a modified version Republicans will now have to own any issues with healthcare, including says Seib things that may not work out for pre-existing conditions- or for groups that are disadvantaged, including older people.

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Under a plan called "premium support" Paul Ryan's U.S. budget proposal would have seniors choose a private insurance plan from a federally operated exchange. Each year the government would pay private insurers a specific amount to cover the cost of premiums with the rest borne by seniors. The total amount paid by the government would go up only at the rate of overall inflation, it would not go up at the higher rate of health care inflation. By doing this the government would take off the trillions of dollars of projected spending on health care that are largely the result of the higher inflation rate in health care costs. This higher inflation rate on health care costs is something that both parties have failed to control, and remains a major weakness in all health care proposals to date, including the Obama health care legislation. Allowed to continue growing at this rate when U.S. debt to GDP is nearing 100%, health care inflation costs pose major risks to the nation's finances.

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A health care practitioner says the real problem is the high cost of medical care in the U.S. when compared to other countries. She points out that the Obama bill in 2008 did not take effective steps to bring down the cost of health care before enacting legislation to cover the uninsured, leading to higher premiums for the middle class. The link between healthcare and profits is seen as the main problem. 

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Germany faces the possibility of a pandemic surge of the unvaccinated, something that is happening today in the southern United States.  For days the percentage of people that are fully vaccinated remains at 62%. Some vaccination centers are closed. A vaccination center outside the train station in Cologne offers passersby free vaccinations. Berlin's Social Democrat mayor Michael Muller is very frustrated. He says "I am now coming to a point where I think we have exhausted what we can do in politics."  At 62% the rate of fully vaccinated people in Germany is too low to prevent a surge of the Delta variant in the way that it has hit the southern US, and California. Vaccination rates of close to 85% are needed to tackle the risk of another surge in highly contagious delta variant. Not everyone remaining is die hard opposed to vaccines. The Robert Koch Institute estimate is that 5 to 10% of people are in that die hard category. The remaining 20-30 % are people who have various other concerns and fears, hesitancy, that may be changed.  The chairman of the World Medical Association Frank Ulrich Montgomery favors a vaccine mandate, what he calls a 2G rule, that should be introduced in Germany requiring vaccination to attend events, sports, restaurant visits, adopted nationwide. German government has rejected idea of mandatory vaccination of health personnel, that was adopted in France. Vaccination drives are regionally based. Some are ineffective such as the Deutsche Bahn train system vaccination drive for commuters that only had a few hundred doses of J&J vaccine and ran out quickly in Berlin. One prick J&J some say is better for vaccine skeptics. Vaccine skeptics think they may get away without getting covid infection. How does one get over this misconception? Others including members of the Greens party say vaccine needs to be delivered where people are- transit points, bus stops, doses offered in evening and early morning hours, trying new ways to reach people and inspire confidence. Germany now ranks behind France but ahead of Bulgaria in terms of vaccination percentage in September 2021, not a good situation. ...

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U.S. Senator Ben Sasse suggests an alternative approach of simply repealing the Affordable Care Act called Obamacare and replacing it at a later date. This is endorsed by president Trump. This is the new Republican strategy in July 2017. Forty nine senators voted in favor of this repeal in 2015, when president Obama vetoed this legislation. Two more senators are expected to support repeal according to Ben Sasse.

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The rarely mentioned origins of the U.S. Medicare reform proposal of Rep. Paul Ryan and Rep. Ron Wyden, which includes work done at the Hoover Institution and liberal think tanks, in a debate subject to distortions on all sides.

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This article in DW.com cites experts who point out that the Republican Party always had tensions within it because of the diverging interests of three groups that have allied together to form the party- Wealthy businessmen and corporate interests, evangelicals, and white working class people who have seen their incomes decline for several decades. The interests of each group have some overlap, are sometimes masked but frequently they diverge. Nigel Bowles, former director of the Rothermere Institute at Oxford University, says there is no particular reason that this coalition would hold together, that it was unstable to begin with, a wonder that it did not split up earlier. Scott Lucas, an expert on American Studies at the University of Birmingham, says that Reagan showed great skill in holding this coalition together, and Donald Trump has taken it apart by mobilizing only one constituency of white working class voters and leaving out others. The break between Republican party leaders Ryan, McCain, and state party leaders, with Trump is unprecedented in post war American politics, and putting it back together now looks like a lost cause in the medium term.  ...