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This article in the NYT provides a look at the features of the Republican House Health Care Plan- Both the Affordable Health Care Act and the House Plan provide incentives for buying insurance- the ACA bases these incentives on income levels whereas the House Plan does not provide additional help for low incomes or elderly. Incomes at $20,000 would see a loss greater than  $2000 under the House Plan and as many of the elderly poor living in high cost areas may not have the resources to make up for this loss of subisidies they may forgo buying insurance or have insurance coverage that protects only in a limited way. President Trump has given assurances that all will be covered. For people with incomes of $50,000 or $75000 the loss of $2000 subisidies would also have some impact. At larger incomes or the well to do the subsidies are not handed out under either plan. Under the ACA the emphasis was on income levels and high cost insurance areas the subsidies were greater, under the House Plan the subisidies would be higher for the elderly compared to the young but very low income levels are not given additional help.     ...

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Alicia Munnell, is the director of the Center for Retirement Research at Boston College. Munnell says the Domenici-Rivlin deficit reduction proposals should serve as the basis for putting Social Security on a sound financial basis. Tackling the budget deficit should not be focussed simply on the 12% of the budget that makes up nondefense discretionary spending in his view. Tackling Social Security would build confidence and reduce the long term deficit. The Domenici-Rivlin plan has the following proposals for Social Security- indexing the full retirement age after it reaches 67 to improvements in life span, a smaller cost of living adjustment, increasing the earnings subject to the payroll tax to about 180,000 from 106,800 in a gradual way, and gradually taxing employer and employee premiums for health insurance.

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With use of the software technologies and cloud computing Athenahealth hopes to revolutionize the medical records of physician practices. Here Joseph Rago of the WSJ talks to Jonathan Bush, CEO of Athenahealth. Bush says the way things are done now in healthcare there is no choice and choosers, and ther is not thing like a market in health care and people in Washington DC don't understand remotely why a market might be remotely useful. The deep problem in American health care he says is that no one knows the actual value of the services doctors give, not even the doctors, and the complexity of the method of payments keeps everything hidden, as doctor's clerical staff bills your treatment to insurance companies picked by your employer, and pays the doctor through money taken from premiums or foregone wages. Athena designed a program to digitize records and automate billing and is moving into clincal record keeping. It now has 15,000 physicians in 43 states using its program as avirtual office and growth at 30%....

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As the final Republican tax bill is debated in Congress on December 19, 2017, Senator Bob Casey cited the following points from the Joint Committee on Taxation Report on the floor of the Senate.  1. Americans building their hopes that their pay checks in February 2018 will be increasing are in for a big disappointment said Senator Ron Wyden of Oregon, a senior member of the Finance Committee. The Joint Committee on Taxation estimate is that for the 57 million families making less than 100,000 dollars a year the tax cuts in the Republican legislation will either not reduce their taxes or reduce the taxes by about $100 a year. 2. The bill does little for the big tasks facing America of rebuilding failing infrastructure. Senator Casey cited 4500 bridges needing repair or replacement in Pennsylvania alone. It also does little for health care access for middle class families and is likely to lead to 10% increase in health care premiums. Affordability of college and other hurdles of middle class and working class families remain unaddressed.   3. The $9 billion in the estate tax cuts would finance the Children's Health Insurance program which has expired.  4. The $36 billion in tax cuts for corporations comes at a time when corporate profits are at the highest they have been in 15 years, according to Vanguard founder Bogle. He also points out that wages as a percentage of GDP are the lowest in 15 years. The tax cuts in the Republican bill are not likely to correct this imbalance.  5. The share of GDP of people making more than one million dollars in 1980 was 11%, this is up now in 2017 to 20%. This has led to questions about the wisdom of these tax cuts which disproportionately benefit a very small percentage of Americans who do not need these tax cuts, and come with significant sacrifices for the middle class in terms of what is available in public services, and the cost to their children as infrastructure and access to health and education is made more distant because of a growing U.S. debt from this tax cut. The big problem then with this bill is that it further damages intergenerational mobility in the U.S., undermining the foundation of a democratic society. Damage has already happened in the past three decades as Federal Reserve chairman Janet Yellen pointed out at a conference on Economic Opportunity and Inequality on Oct. 17, 2014, saying-"The past several decades have seen the most sustained rise in inequality since the 19th century after more than 40 years of narrowing inequality following the Great Depression." This is why there is substantial agreement in the media from the Wall Street Journal's Greg Ip to Krugman in the New York Times that the bill fails to correct a harmful trend, and goes further in the wrong direction for a democratic society.       ...

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How the French health care system works. France comes in first and the USA 37th in aWHO health care ranking. THe difference in deaths from respiratory disease is half that in the USA, and lower rates of death from heart disease and diabetes. IT has more hospital beds and doctors per capita than the USA. 65% of French people are satisfied with their health system compared to 40% in the USA, and yet France spends 10.7% of GDP on health care and the USA spends 16% for poorer results. THe French system is more generous to its seniors. Unlike Medicare there are no deductibles, just modest co-payments that are often dismissed for chronically ill. And diabetes and critical surgeries are covered 100%. French also buy supplemental insurance like Medigap for extra expenses like dental and eyglasses. Cancer patients are treated free of charge. Avastin treatments costing $48,000 a year are provided at no charge. France's PMI or Protection Maternelle et Infantile, is rated highly. It is anetwork of thousands of healthcare facilities, that ensure that every mother and child in the country receives basic preventive care. Mothers even receive afinancial incentive for attending their pre and post natal visits. France makes this care affordable by reibursing doctors at a much lower rate. The average yearly net income for doctors is around $55,000, about athird of what doctors in the USA make. But French doctors don't have to pay back huge student loans as medical school is paid for by the state and malpractice insurance premiums are only a tiny fraction of that in the USA. And again the French government pays two thirds of the social security tax for most French physicians- which is typically 40% of income. So the $55,000, is more like $92,000 taking that into account and more like $110,000 when student loans and malpractice is taken into account at US levels. Specialists who have 4 or more years experience can charge what they want, but as one gastroenterologist says, there in an unspoken and undefined limit to what you can cahrge or what is socially acceptable. Yet even in France there is inflation in health care costs that the government deals with through price controls and more spending. The French national insurance system is running increased deficits each year and this is now $13.5 billion, and it has led to higher taxes for employers and workers. ...

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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 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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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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The startling truth about health "reforms," - they won't control spending, and without that the whole system of health care will rapidly become unaffordable and unsustainable. Obama's Council of Economic Advisors points out in new report that since 1975 annual health spending per person, adjusted for inflation has grown 2.1 percentage points faster than overall economic growth per person. At this rate health spending which was 5% of the GDP in 1960, and is 18% of GDP today, would grow to 40% of GDP in 2040. Medicare and Medicaid would increase from 6% of GDP now to 15% in 2040, or equal to three fourths of federal spending. Employer paid insurance premiums for families which grew 85% in inflation adjusted terms from 1996 to $11,941 in 2006, would increase to $25,200 by 2025 and $45,000 in 2040. This would force employers to reduce take home pay. Samuelson says the uncontrolled health spending is singlehandedly determining national priorities, reducing discretionary income, raising taxes, widening budget deficits and squeezing other government programs, while it is producing large amount of waste in medical spending. See the link to Prof. Tyler Cowen of George Mason University in NYT, 6/14/ 2009, who cites the habit of doctors to write many expensive tests as one of the prime culprits in the wasteful spending. And in the process it delivers higher cost for lower overall quality of health for the American people. This at a time when many European countries provide live examples of doing it in a better way- lower cost, better health. The serious problem with the Obama health reforms says Samuelson is that it talks about restraining spending but may end up increasing spending. Its talk about controlling spending he says is good intentions, but based more on hopeful thinking, public realtions and risks becoming cosmetic reform. Because to really control spending will require coming to grips with its fundamental cause- hospitals and doctors are paid mostly on a fee-for-service basis and reimbursed by insurance, private or governmental. Such a system encourages doctors and hospitals to provide more services, expensive tests, favors heavy use of expensive medical technologies to increase profits, and for patients to expect them. Samuelson puts his finger on the root of the problem - there is no incentive and every disincentive for all the players in this game , doctors, hospitals and patients to seek reform of this system. For doctors and hospitals the hope would be that this cosmetic "reform" would leave the system basically unchanged, and patients to continue with a lifestyle and expectations that do not not acknowledge the fact that a lot of healthcare does not come from spending but from preventative care, education, good eating and exercize habits, and healthy lifestyles. And the uninsured are no exception, they would simply start consuming the expensive care for lower quality of overall health like everyone else. With this kind of situation confronting us, the views of Samuelson, and Professor Tyler Cowen of George Mason University, as welll as a growing chorus of informed public opinion on this subject, is that insuring the uninsured is a good idea, but doing it within the bounds of the present system, can only increase the costs. And too much is at risk, to rely on what Samuelson calls a scattershot of measures to control costs made up by Congress such as "evidence -based guidelines," "electronic record-keeping," "bundled payments to hospitals, to give the illusion of progress that won't make a serious difference. A sweeping restructuring of health care is needed, that would overhaul "fee-for-service" payment and reduce the fragmentation of care. It will also need what has not even be touched on adequately in the debate. This is the massive need for education in the schools about nutrition, eating, exercize, healthy lifestyles. It would also require opinion leaders in each field from sports and other fields to lead by example and with constant public presence, the media, and companies to form a partnership with private institutions to change existing eating habits and lifestyles that encourage obesity, smoking, fast food eating habits, large portions in restaurants....

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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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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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The coverage of the Republican healthcare bill and how it affects the elderly, and people on Medicaid, people in rural areas, is likely to have changed public opinion in the U.S. about the necessity of ensuring all Americans have health coverage. The Pew survey cited here in this NYT report by Zernike and Goodnough was done in Jan 2017, and shows a shift. The shift would be much higher today after people look hard at the consequences of what were simply hypothetical positions or ideological positions taken without looking at consequences in daily living. On Medicaid that opinion by July 2017 compared to Jan 2017 has shifted 10 percentage points for Republicans to 53% who think Medicaid is important to them and their families, according to Kaiser research. There is stronger sentiment about people having benefits taken away.  [article-55059] The opinion has shifted to where people see that coverage is important and people should not have coverage denied or benefits taken away from them. Opinion remains strong in favor of changes to reduce the high premiums, but not to replace the existing health benefits and law with no law at all to replace it. That leaves 20 million more uninsured according to the Congressional Budget Office. Changes have to be constructive is the popular view today,  and this requires dialogue between Republicans and Democrats- which has not taken place. ...

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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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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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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.  ...