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Krugman talks about the misunderstandings and the whole lot of misinformation that comes from advertising and political commentary. With one man telling a Congressman at a town hall meeting: "keep your government hands off my Medicare." In apolitically charged atmosphere this makes rational decisions in acalm thoughful environment difficult or impossible- when the influence of lobbying by the health care industry and the influence of interests on behalf of patients and other interests have already created a difficult situation.

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Dionne cites comments by Bowles and Simpson saying the Paul Ryan U.S. budget proposal falls short of a serious bipartisan effort for deficit reduction for a number of reasons. The reasons cited by Bowles and Simpson are: The proposal exempts defense spending from reductions, does not apply savings from tax expenditures to deficit reduction, relies on much larger reductions in domestic discretionary spending than the Bowles-Simpson deficit reduction plan, and at the same time making reductions in safety-net programs that could in their words "place a disproportionately adverse effect on certain disadvantaged populations." This should give moderates in this debate time for pause and reflection says Dionne.

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Doctors face a 21% cut in the amount of Medicare payments for treating seniors having Medicare, though this cut will be delayed till 2011 under legislation in Congress. This issue goes back to 1997, when a budget law set spending targets, and stated that if they were exceeded formulas to reduce doctors payments would go into effect. The formulas seriously cut into doctor payments by Medicare in 2002, so the formula was put off. The result of this is that the cuts based on the formula now amount to 21%. The cuts are not expected to go through, but at the same time Congress has an headache on its hands with the growing deficit. In the Senate there is opposition to a $120 billion bill to extend long term unemployment benefits which lapsed in June 2010, for tax breaks, and other expenses. Senators want to pare down the bill's price tag, as $80 billon of this is unfunded and will be added to the budget deficit. For a primary care doctor in Washington state, Medicare pays about $95 compared to private insurers payment of $129, and a plan for state workers that pays $140....

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The Congressional Budget Office's Elmendorf says without spending cuts in payments to doctors and hospitals and other providers, providing coverage to the unisured will put the nation deeper into debt. Popular measures such as increasing preventative care, expanding medical records and rewarding doctors for choosing treatments that improve cost and quality have potential but its not proven how much the savings from this would be. The administration and the White House Budget Director, Peter Orszag, say they are in agreement with the CBO that something needs to be done to seriously reduce costs, reducing payments for Medicare and Medicaid to doctors and hospitals, and making other changes.

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Medical device makers for heart like the stent and hip like replacement hips have margins of over 70%. THese and other medical devices may come under pressure from the changes that are anticipatd in the way Medicare reimburses hospitals for these devices, which are largely used by older patients under Medicare coverage. Stocks of these device makers like Boston Scientific, Stryker, and Zimmer, have fallen in recent weeeks

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Romney picks seven term Wisconsin Congressman Paul Ryan as his running mate for the 2012 U.S. presidential election. It is a daring pick because Ryan has clear ideas about reducing the U.S. deficit which are in sharp contrast to the approach taken by Obama and Biden, offering American voters a clear choice. This is similiar to the contrasting choices between Reagan-Bush and Carter-Mondale during a period of high unemployment and inflation in the 1980 presidential election. The contrast was also made clear by the release of the Shultz memo to President Reagan and the comparisons with the Reagan election by Romney economic advisor Glenn Hubbard, both recently published in WSJ.

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Leonhardt points out a couple of problems with Paul Ryan's budget proposal for Medicare. He says Medicare recipients, with the exception of the very affluent, currently haven't paid enough for the benefits they receive. He cites a study that shows Medicare pays out several hundreds of thousands of dollars for the average retiree more than they ever paid in. Medicare funds go for hospital expenses, the rest for doctors bills come from general government revenues. Government borrowing increasing the national debt to unsustainable levels so that current retirees do not have to pay higher taxes, is simply shifting the burden to the next generation. He says the Ryan plan shields those who will retire in the next 10 years because they are a powerful voting bloc, making this more of a political calculation than a bold reform step, as this means younger people will have to bear a disproportionate share of the burden. The other part of Ryan's calculus is that it has proven extremely difficult to reduce the volume of medical care that is consumed in terms of tests, lack of preventive care leading to graver problems, and surgeries. Simply by shifting a larger share of the cost to future retirees this will have an effect on the volume of medical care consumed and put a lid on costs. This is something that needs to happen says Leonhardt, but at the same time all Americans need to share in the higher taxes that are necessary to fund Medicare, exempting 75 million Americans only creates an imbalance in contributions. The other problem with this is that the costs of this exempted group will postpone serious deficit reduction for ten years....

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Tyler Cowen, Professor of Economics at George Mason University, points out some basic truths about health care as it is practiced today in the USA, and healthcare spending as it stands today. He questions whether starting out with extra spending plans to provide coverage to all will help solve the basic problems facing American health care. Too many tests and diagnostic procedures used by doctors is not aproblem that will be solved by spending more money to cover everyone. And government taking on more spending to cover all will not address all the other major shortcomings of the American way of practicing medicine, like prescribing a battery of tests, that tend to drive up costs, to just mention one of the problems. And it will not address any of the shortcomings in the way Americans take care of their health, diet, exercize and healthy lifestyles. THese are critical to get good health outcomes for the people, and which combined with careful spending of dollars where it will provide the greatest benefit, is the only way the health care solutions can be found....

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Alan Meltzer would like to see the Fed reverse its quantitative easing, and lower excess reserves gradually starting now. By this he hopes to see the Fed avoid the mistake of making a big shift from excessive ease to severe contraction further down the road. He also warns agains excessive deficit spending. He says a weak economy is not the time to cut spending or raise taxes, and he is not talking of draconian immediate steps. He would like to see a multiyear program to increase fiscal probity and reduce deficits size and frequency. As it stands now he takes both parties to task for lack of fiscal discipline and honest accounting. About $1 trillion in deficits each year on average for next 10 years is in the works, and is an underestimate because the savings of $200-$300 billion in medicare spending have still to be realized, and states do not have funds for increased Medicaid spending, and payments to doctors have still to go down by 25%. Chinese government purchases of half our debt will postpone the day of reckoning says Meltzer, but far better for us to strike at the problem now, before we blow a hole in the dollar and start a downturn. See the separate report on the shrinking UK economy....

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A Feb. 2011 NBC/Wall Street Journal shows only a small number of Americans think cuts to Medicare are necessary to "significantly reduce" the deficit. Only 18% favored cuts, 54% opposed cuts to Medicare to reduce the deficit. Only 22% said cuts to Social Security were needed, 49% said they were not needed. Tea party supporters by a 2 to 1 margin said significant cuts to Medicare were "unacceptable." What measures should be taken to put the entitlement programs on a sound financial basis? On this point over half of the people polled said they favor increasing the retirement age to 69 years by 2075, up from 66 now. A larger number said they support reducing Social Security and Medicare payments to wealthier Americans. Experts say these two measures could eliminate 60% of the underfunding of Social Security. On the issue of collective bargaining rights of public workers, this poll shows 62% of the people polled oppose effforts to weaken collective bargaining. This is similiar to the CBS/New York Times poll results of Feb 24, 2011 on this issue. See the group for this. This poll show a big yellow caution light for Republicans zealously advocating cuts to entitlements. Both polls show lack of public support for reducing the collective bargaining rights of public workers....

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A plan to postpone a 21% cut in payments to doctors for treating Medicare patients, and instead give a slight payment increase under a House proposal, at a total cost of $245 billion over 10 years, is raising questions about the the impact on the USA budget deficit in coming years. The Congressional Budget Ofice says the House health bill will increase the deficit by $239 billion by 2019. In past years the lawmakers in Congress have postponed the implementation of these cuts, and the administration would like to see this as a separate item and not showing increasing the deficit. The American Medical Association lobbied to have this provision in exchange for its support to the health care plan.

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The first budget of the Obama government makes a sharp swing away from decades of earlier policy, and puts America on a new direction focussed on priorities in education, health care for all, and energy. The 134 page doocument on the budget defines the governing principles and priorities of the new government. "This is the legacy that we inherit- a legacy of mismanagement and misplaced priorities, of missed opportunities and of deep, strutural problems ignored for too long," the document says. It declares that "government must lead" in contrast to Reagan's "government is not the solution, government is the problem." In contrast to "trickle down" policies of Reagan it proposes "trickle up" policies- shifting income from rich to the poor. It creates a $630 billion fund towards a national health insurance program built with the help of savings and cuts elsewhere. Government takes over most student lending, and dramatically expands Pell grants for poor college bound strudents, transforming it into something like Medicare that is automatic rather than approved each year by Congress. Businesses that emit carbon and heat trapping gases will have to purchase permits to do so starting in 2012. Hundreds of billions of dollars from these permits will pay for clean-energy technology and for tax credits for working couples. Income tax rates will rise for couples earning more than $250,000 beginning in 2011 and will have lower personal exemptions, lower itemized deductions, and higher capital gains tax rates. The estate tax will be preserved. Hedge fund and private equity managers wil have to pay income tax rates for that compensation as high as 39.6% after 2010, not the low 15% capital gains rate they pay now. The Defense Department would see a $20.4 billion boost or a 4% increase in 2010 over 2009, it will request an additional $75.5 billion in 2009 for the wars in Iraq and Afghanistan, and an additional $130 billion for 2010. The budget is for $3.6 trillion for 2009, and projects a deficit of $1.75 trillion for 2009, or 12.3% of GDP- a level see in 1942 when the US entered World War II. Under optimistic White House assumptions for a strong economic rebound, the deficit would drop to $533 billion by 2013....

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The discussion on whether it is feasible to achieve any significant cost savings as long as middle class consumers are not cost conscious about their employer provided health insurance. This would be so as long as their health insurance benefits are not taxed as income. America suffers from a particularly strong case of not minding the price increases imposed by the health care industry as long as its not out of pocket cost. But Obama seems stuck on his insistence that the middle class not take on any burden, that there be no middle class tax in the form of this tax on health care benefits. Critics say even FDR did this by having the middle class pay with payroll contributions for Medicare and Social Security. And even if the 5% of Americans who make more than $280,000 are taxed it will not generate by itself the money to pay for the $1 trillion cost of the plan, as the prospects of cost reduction are uncertain- especially when the basic nature of America's health care system are not changed, like the lack of cost consciousness of consumers of health care when its perceived to be free and employer provided....

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Krauthammer cites Congressional Budget Office numbers that show the Obama U.S. health care law continues the spiralling costs of health care with new government mandates at a time of severe budget cuts in education and other areas- for 2013-2022 the costs come to $1.76 trillion. The initial Obama administration figures of 10 year costs of $938 billion announced in 2010 reflected the fact that the new U.S. health care law would take 4 years to fully go into effect. Costs after 2021 are shown to be $250 billion each year in the CBO figures. The law is now before the Supreme Court in 2012, which has to decide on the basis of the limits of the Commerce Clause.

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The Economist cites the Dartmouth Atlas Project which shows differences in cost across the country for health outcomes and spending involving Medicare. It cost $5000 per person in Salem, Oregon in 2006, $8000 in San Francisco, and more than $16,000 in Miami, with outcomes for health tending to be better in places where the costs were lower. This is one of the statistics that Peter Orszag of the Congressional Budget Office uses to come up with his estimate of 30% waste in health care spending in the United States. Prof. Skinner at Dartmouth and Prof. Garber at Stanford point out that of most health systems around the world the American system is "uniquely inefficient" and wasteful. The Economist cites information that the American system is twice as costly per person for healthcare than the Swedish system, and that it costs twice as much in Minnesota as in Miami. A poll done for the Economist shows 52% of the people in the UA are dissatified with the quality of care, 40% think the system needs fundamental change, and 29% think that it should be fundamentally rebuilt. The lack of uniform coverage is also causing turmoil in the system. About 49 million are uninsured, and a quarter or more are able to buy insurance and do not buy it because it is so costly, has exclusions and coverage is inadequate. But these people also end up in the emergency rooms along with the indigent costing the whole system tens of billion of dollars for costly late interventions that could have been avoided with preventive care early on. With the economic crisis and rise in joblessness, the dire condition of state and local budgets, the situation has probably drastically worsened, and the system near breakdown. ...

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Amy Goldstein spends time in Janesville, Wisconsin, in U.S. vice presidential candidate Paul Ryan's congressional district, and talks to local people to give a glimpse of life in Janesville after the closing of the GM plant and the 2008 financial crisis. She looks at the effects of long-term unemployment and cuts in services in communities such as Janesville as a public policy scholar at the Woodrow Wilson International Center for Scholars, while on leave from the national staff of the Washington Post. Ryan was first elected to the U.S. Congress in 1998, about a decade before the closing of the GM plant, and has been reelected to Congress each time for 7 consecutive terms. Goldstein says Janesville is typical of the communities across America that have suffered job losses- the loss of more jobs in manufacturing than any other sector, a greater impact of job loss for men than women, and a large impact on people who had less education but well paid jobs. As shown by the recent settlement for a Caterpillar plant in Joliet, Illinois, and across the U.S. manufacturing landscape, older workers who enjoyed higher wages are retiring with newer workers coming in at a lower wage, which is improving U.S. manufacturing competitiveness but also increasing the importance of education for higher paying jobs....

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Bowles and Simpson call for deficit savings along the lines they suggested as co-chairmen of the President's Deficit Commission- reducing the cost increases in Medicare, changes to Social Security, and cutting tax expenditures.