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Some features of the U.S. health care law are likely to be retained even if the Supreme Court overturns the health care law- the feature that lets parents carry a teenager on their polcy till age 26, and the feature that private insurers cover preventive services without copays. These are very popular and preventive services make sense for the insurance companies to reduce higher costs later on. Other features such as the discount pharmaceutical companies must give to seniors falling under the Medicare gap, and annual physicals without copays may not be retained. 3.6 million Medicare benificiaries saved $2.1 billion on prescription drugs, $604 per person, from the Medicare gap discount. And 32.5 million Americans took advantage of the annual physical without co-pays in 2011. About 50,000 Americans insured temporarily for people with a pre-existing condition also may lose their coverage. Another provision which prevents states from tightening eligibility rules for Medicaid before 2014, may be questioned also as states feel burdened by these rules during a period of budget cutting in areas such as education....

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AARP shows 29 million Americans working and taking care of older parents. Many work 40 hours a week and work an additional 20 hours helping elderly parents. About six out of ten people of this 29 million work full time. In 2024 a lot more people are living longer and older people prefer staying in their own homes and need help from family members. A simple fall or a cancer diagnosis can lead to long hospital stay, months of treatment, and worrying for family members. Company benefits in 2024 do not include senior or eldercare support or even accomodating employees caring for their parents. In America today federal and state laws do not protect people caring for elderly parents from discrimination in the workplace. Consider how this is affecting companies, as about one third who are caregivers say they are going to leave, and half of the employees leaving are senior manager and executives with much experience. This comes to about 5 million senior managers and executives that American industry can ill afford to lose as it competes with China, India and Europe. About half of all companies are making this a priority in 2024, according to Care.com. Citigroup added 2 weeks of paid leave to care for immediate family member. Companies allow employees to add older parents on their health insurance. These benefits are being added to maternity and paternity leave. The fact that Congress and state legislatures have failed to enact laws protecting caregivers is one more reason for the discontent and unrest in the US after the pandemic. ...

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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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David Segal takes a detailed look inside Apple's retail stores in the U.S. and talks with employees at different stores to find out what its like working as an hourly employee at an Apple store. World wide Apple's 327 global stores sold $16 billion in Apple products. Per employee the sales are about $473,000, but at an hourly rate of about $12 the average employee makes about $25,000 per year. After recent wage raises this could be up to about $36,000. The National Retail Federation says electronics stores have about an average of $206,000 in sales per employee. Contrary to what most people may think most of Apple's employees are not engineers and other professionals, about 30,000 of the 43,000 Apple employees in the U.S. work as hourly employees in the retail stores. Most are young people in the early 20's, single, with health insurance provided by Apple not costing as much for that age group. There is no career path and most leave after a couple of years. Because of the Apple mystique and the drive to create new user friendly products there are many young people looking for this kind of temporary work, especially now with high unemployment. ...

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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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Walmart comes out in favor of requiring employers to provide health insurance to all workers, a central feature of President Obama's effort to provide near universal coverage in the USA. As the country's largest private employer, employing 1.4 million Americans, this change is significant. In a letter to the President, Walmart CEO Mike Duke, joined by Andrew Stern of the Service Employees International Union, and John Podesta of the Center for American Progress, who also signed the letter, say they are for an employer mandate which is fair and broad in its coverage. Walmart had a couple of reasons for doing this. For one Walmart needed to join the negotiations, as the Senate Finance Committee is considering other proposals that are less favorable to Walmart than employer mandate. Already Walmart is covering 52% of its employees, and has improved health benefits in recent years in response to criticism of the company. The industry average is 45%, according to a 2008 Kaiser Foundation study, and some companies do not provide the health benefits that Walmart does, so this helps level the playing field by requiring all large companies to share the burden. Walmart wants to see effective cost controls to keep costs down, and Rahm Emmanuel, the President's chief of staff, assured Walmart that "cost control and employer mandate are heads and tails of the same coin." Under the plans considered by the Senate Finance Committee under Max Baucus, small businesses are exempted from the employer mandate. Republicans have opposed employer mandate. And the U.S. Chamber of Commerce has opposed it saying it would make companies lower wages and cut jobs. Walmart's shift has been gradual. From a company used to providing skimpy benefits, it has evolved as it improved benefits, and two years ago it joined the SEIU union to call for affordable health care for all Americans by 2012. It has Mr Dach as its governmental affairs vice president, and this is significant, as Dach is an advisor to Democratic party politicians....

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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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Zaraska says a vegetarian diet or one that includes vegetarian diet in meals is a good idea to reduce the risk of heart disease, obesity, diabetes and other medical problems. Be sure to add zinc, iron and calcium, Vitamin B12 to the diet if you are older she points out, to compensate for the change. About 2.5 million Americans over the age of 55 are vegetarian according to a 2012 Harris poll done for the Vegetarian Resource Group. There is a common perception of vegetarianism as purely vegetable type foods. However vegetarianism in India is practiced with the inclusion of all dairy products- milk, yogurt, and buttermilk. Not only are they included, they play a significant role in the diet. Also included and playing a large role in the diet are lentils and beans which provide a significant source of protein. When the idea of vegetarianism is broadened to a more normal vegetarianism as practiced in countries like India and includes dairy, lentils and beans, the diet is able to provide most of the nutrients needed. By including this kind of vegetarian food as an integral part of the diet and reducing meat is another way the health needs of Americans facing a high rate of obesity and other medical problems can be met. If insurance companies were to give incentives for increased consumption of these vegetarian foods and lowered consumption of meat, and the public was made aware of its benefits through advertising, the cost of health care in the U.S. could be brought down....

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U.S., UK and Swiss regulators charged UBS AG with conspiracy to rig the London Interbank Offered Rate or LIBOR. LIBOR is the interest rate at which large banks lend to each other and is determined from daily reports made by 16 banks to the British Banking Association, giving the rate at which the bank borrows from its peer banks. This rate helps determine the rate for trillions of dollars in securities, home and auto loans, swaps and derivatives. A tiny movement in LIBOR can affect trading profits, and it influences perceptions of a bank's health particularly in a crisis such as the 2008 financial crisis. Every day a 16 bank panel reports this rate to British financial authorites. UBS took full responsibilty and pleaded guilty to criminal fraud. UBS settled the charges for $1.5 billion. Barclays PLC, a UK bank, settled charges for LIBOR manipulation in mid 2012 for $450 million, ending in the departure of the bank chairman and CEO. Britain's regulator the Financial Services Authority, FSA, says in its report that rigging the rate was "routine and widespread" at UBS in order to increase trading profits, done with the knowledge of senior managers, and included cash awards or trading opportunities to employees at other banks to participate in manipulating the LIBOR rate. During one period of 18 months UBS paid 15000 British pounds to a firm of outside brokers every 3 months. FSA says LIBOR and versions of it are "at risk of being improperly influenced " between Jan. 2005-2010. What this means is other large settlements with other banks can be expected. Fannie Mae and Freddie Mac may have lost $3 billon from this manipulation of LIBOR, according to an internal report from the inspector general of the Federal housing Finance Agency, which also says Fannie and Freddie should sue the banks responsible. The whole issue of LIBOR came to light after an article was published in the WSJ, April 16, 2012, and a WSJ study on LIBOR using credit default insurance to track LIBOR rates, on May 29, 2012....

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Jim Dwyer discusses proposed legislation in the New York City Council in November 2011, to set a "living wage" of $10 per hour, plus benefits, for workers at new developments receiving more than $1 million in public money. Under this legislation employers who do not include benefits would pay an hourly wage of $11.50. Discussion in the City Council has led to questioning this legislation on the grounds that the developments would not be built under the new rules. Dwyer points to San Francisco, which has set the minimum wage at $10.24 for January 2012, plus mandatory contributions to health insurance funds. The number of low wage workers in New York City with some college education has increased by 70%, according to the Fiscal Policy Institute. Wages at the bottom were $10.85 an hour, adjusted for inflation in 1990, in 2010 the wages were $10. What this does is further increase the income disparities and inequality in the U.S. Because of the demographic changes in America with Hispanic children representing a large proportion of young children, and the high rate of dropouts from highschool in the Mexican American community in New York, this means more children in New York City growing up below the poverty line....

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This Economist magazine editorial says the Republican plan for health care with its roll back of Medicaid expansion by limiting funding to states after 2020, and by scaling back subsidies especially for older Americans and not basing them on income levels, is likely to have its own problems just as the Affordable Care Act. One concern is that keeping healthy people in the market with a mandate that everyone have insurance is present but in a milder form with premiums going up by 30% in one year if they change their mind. There is concern that this may not work among insurers leading to an increase in premiums, pricing people out of the market in "a death spiral." This could lead to more people being priced out of the market as premiums rise. About 12 million people were added to Medicaid by increasing eligibility level to $16400, or 138% of poverty line- this reduced the uninsured from 16% in 2010 to 8.8% today. The Economist concludes that the Republican health care bill has its own problems, and that this bill does not clear up the problems in Obamacare by substituting Ryancare as the Republican bill is called. Peggy Noonan writing in the WSJ says this may have negative consequences for the new Republican base shift to populist support. Critics on the right like Rand Paul see even the reduced subsidies as an entitlement program, yet the Republicans can only change parts of the Affordable Care Act as they need 60 votes in the Senate where they only have a small majority.   ...

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A detailed breakdown of the the waste, fraud and improper payments in federal spending is shown in this WSJ report. . Of $4.1 trillion, a big chunk of the $6.7 trillion the US had in federal spending in 2024 according to CBO, 3.7% is self identified by agencies as improper payments or $149 billion. 90% of improper payments are overpayments. It reached a high of 7.1% of federal spending in 2021 during the pandemic when loose controls led to more improper payments. Only $22 billion was recovered for 2024. Outside agency control including state and local control where the federal and states are running programs is the single most difficulty in getting improper payments back. Top government programs with improper payments are: Health and Human Services Medicare $31.7 billion Medicaid   $31.1 billion Medicare Advantage $19.1 billion Medicare Prescription Benefit $3.6 billion Treasury - Earned Income Credit $15.9 billion Agriculture- Supplemental Nutrition Assistance $10.5 billion Social Security Supplemental Security Income $6.5 billion Labor- Federal and State Unemployment Insurance $5.1 billion ...

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Mnay people who have engineering degrees and jobs which pay 60,000 to $75,000 in the auto companies are now visiting food banks as they exhaust their unemployment benefits. They live in suburbs of Detroit, in Rochester Hills, in Dearborn Heights, in Taylor and so on. THe unemployment rate has reached 14.1% and there are more layoffs ahead. THis is also affecting the health care business as companies cut benefits. By the end of of 2009 100,000 residents will have lost their benefits, according to the state's unemployment insurance agency. THe US Department of Agriculture provides 20% of the food aid in the state to food banks and is watching the situation closely. In May, the caseload of the Michigan Food Assistance Program, which adminsters the USDA's food stamp aid for the state rose to 719,000 households, up 3.1% in April and nearly triple the figure in 2000. THe USDA has doubled its shipments to Gleaners, a food bank, which says it is stretched, as it does not serve the once affluent suburbs....

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In this Agenda column Simon Nixon takes on the U.S. Treasury's criticism of Germany for its current account surplus of 7% of GDP in 2012, and not doing enough for the economies of southern Europe. The German government called it "incomprehensible." Nixon says it is better for the German economy to remain strong and to boost competitiveness and consumer spending in Spain, Portugal, Italy and Greece. He says the low eurozone inflation of annualized 0.7% for September 2013, which prompted the ECB to cut rates by 0.25%, is healthy to the extent that consumer prices are declining to adjust to a decline in wages. The reduction in labor costs is a way to restore lost competitiveness, just as Germany did in the last decade. The criticism is considered by many economists to be misdirected, and seen as "incomprehensible" by Germans, as Germans ask what would the U.S. have them do- provide stimulus when the government debt to GDP ratio is currently 82%, increase wages and how would this help Southern Europeans. Focussing on Germany's current account surplus says Nixon, is obscuring the larger issues of increasing consumer and business confidence and spending in the eurozone, and increasing bank lending. The new ECB bank resolution arrangements and other changes including deposit insurance if done right should help the recapitalization and restructuring needed for restoring bank lending to support recovery. Spain is furthest along in regaining competitiveness, with changes in Portugal, Italy and Greece also supporting a gradual return to growth....

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Community Aging in Place: Advancing Better Living for Elders, has been here since 2009, it is offered in about 65 places across 26 states. in the US. It helps people 60 and up stay in their homes such as Chikao Tsubaki 87 years shown here in the Washington Post. It brings a repair worker into the home to figure out how to make it safer for falls, in addition to an occupational therapist and a nurse. Center for Disease Control and Prevention says these falls contribute to deaths of 41,000 older Americans each year and cost Medicare $50 billion. Yet this report in The Washington Post shows Medicare does not cover it, and most private insurance plans do not grasp the idea of keeping people healthy in good settings, paying only when people fall, doing little to prevent the falls. Sarah Szanton is a nurse practitioner who worked with older Americans in home settings in West Baltimore and started CAPABLE in 2009, and is now Dean of the John Hopkins University School of Nursing. In it the client and care team work together to do problem solving and brainstorming. One study shows $20,000 in savings a year for Medicare continuing for 2 years person after one CAPABLE intervention. ...

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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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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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What Krugman makes of the $1.089 trillion dollar U.S. deficit for fiscal year ending in Sept. 2012. He points out that the U.S. can have a stable to declining debt to GDP ratio with $400 billion debt. He cites the Clinton years (1992-2000) when the debt to GDP ratio declined from 49% to 33% with steady growth. What about the remaining $600 billion. He attributes this mostly to temporary factors which are reversible as growth picks up. Of this remaining excess deficit he says $400 billion is from lower tax payments to Treasury because of the 2008 economic crisis and the recession that followed. This includes the payroll tax cut which is also temporary to keep up consumer spending in the recession. The $150 billion is from unemployment insurance, food stamps, and other aid which is also reversed once growth picks up. He places emphasis on restoring economic growth as early as possible and reducing unemployment and using the recession for business to continue to invest in R&D, productivity, and government to preserve the social fabric, invest in education, and provide incentives for growth. S&P Nov. 8 report says the net government debt to GDP ratio is estimated to be over 80% in 2013. It will have to stabilize at current levels for S&P to preserve the U.S. credit rating, says S&P executive Chambers. The higher debt to GDP ratio in 2013 and lower growth rates expected makes the situation different from the lower debt to GDP ratios during the Clinton period. Britain, France and other major industrialized nations with political parties at either end of the political specrum have also chosen to stabilize or reduce debt to GDP ratios rather than take on the risks of them going much higher. The U.S. has the added problem of health care costs out of control with an aging population and about 17.9% of GDP going to healthcare costs in 2010 expected to increase significantly, as Medicare actuaries estimate enrollee numbers jump to 80 million in 2030 from 50 million in 2012. Democrats and Republicans have largely sidestepped this underlying problem in fiscal cliff negotiations....

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Serious problem of rapid premium increases for middle class people not eligible for subsidies under the Affordable Care Act. Insurance companies have increased premiums rapidly to pay for the cost of treating people with previous conditions and the uninsured, as well as population with poor health conditions.

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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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Health insurance premiums for family plans increased by 9% in 2011 according to a survey by Kaiser Family Foundation. A similiar survey by Mercer showed premium increases around 6%. Another change is that health insurance plans are becoming less comprehensive and deductibles are higher, with higher copays and employees contributing more to premiums.