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China plans $29 billion of local bond sales (200 billion yuan) through the central government, to meet the needs of cash strapped local governments. Its proceeds would go to projects approved by Beijing, for airports, power plants and railroads. In earlier year local governments depended on land sales as abig source of money. China's tax system sends most revenue to the central government, while provincial and municpal governments are left to handle most of the spending on education and healtcare, which is why these needs may not be getting the funding they need. Land sales are now drying up as asource of money as the property market declines. This does not mean that the local governments are not indirectly taking on debt. Chinese law prohibits cities and provinces from taking on debt without Beijing's approval, but companies owned by local governments have borrowed heavily to fund public works projects. Shanghai Chengtou Corporation, a municipal government company that builds infrastructure has taken on 200 billion yuan in debt in 15 years. Economists say this kind of debt may be 20% of annual GDP, which added to the central government debt of 20% of GDP, would bring the combined debt to 40% of GDP. What this new effort does is make the taking on of new debt official and more transparent. The principle behind the earlier tight control of debt issued by local governments was to prevent local governments going overboard and the central government having to take responsibility, as happened in the 1990's in India, Mexico, Russia and in the USA....

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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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The loss of some 4 million jobs is expected by experts in 2009, and Obama economic advisor Christina Romer has presented information at a meeting that shows the current downturn will be more severe than anything we experienced in the last 50 years. At that meeting on December 16, 2008, Obama met with Romer and other economic and policy advisors for 4 hours. It was decided that the target for jobs should be 3 million jobs created in 2009 and 2010. This still means a lot of the 4 million job loss will still occur in 2009, even if the infrastructure jobs estimated at $136 billion by the nation's governors get off to a fast start as they are supposedly ready to go. Money to states and local governments will reduce job losses and loss of services, and money in the form of lower payroll taxes would probably be saved to reduce debt by the public. Money to the poor to support medicaid and health care services and expanding healthcare coverage for those who lose coverage will be safety net reinforcement and support. So finding places to spend where jobs can be created quickly will be a challenge going forward and some of the $1 trillion stimulus will not go directly to job creation but as support. For the December 16 meeting Romer consulted with Martin Feldstein the senior Republican economist who said that " without action the economy will continue to decline rapidly." For a long time Martin Feldstein has been advocating strong action especially to reduce foreclosures and help stabilize housing prices. As the economy has weakened he has revised upwards what needs to be done, and his estimates are close to the lower end of the $800 billion to 1.3 trillion that is being estimated for 2 years. Lawrence Lindsay and other economists are supporting upto $1 trillion stimulus. ...

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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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Questions about the true cost of the Obama health care legislation and the assumption that the legislation cuts the deficit by billions of dollars. This WSJ editorial says one has to look at this closely, and not merely look at CBO projections, which may be based in a certain context and not reflect the true costs, especially because many accounting gimmicks and use of numbers to present a particular picture is taking place. The information this editorial cites is that: it uses 10 years of taxes to fund six years of subsidies, Social Security and Medicare revenues are double-counted to the tune of $398 billion, a new program funding long-tem care frontloads taxes but backloads spending, and the assumption of an automatic 25% cut to physician payments that Congress is unwilling to authorize. Rep. Rand Paul has tried to present an alternative view which needs to be studied just as closely, because of the enormous impact of a jump in spending at a time when the public finances are fragile. WSJ also cites the work of Richard Foster, the chief Medicare actuary, as an alternate perspective of how things could turn out, Doug Holtz-Eakin, and Eugene Steuerle. It calls for common sense in evaluating programs, entitlements, defense or other government spending. They not only cost money, but costs escalate over time as history has shown over decades, till they eventually are discovered to be not affordable unless the middle class is willing to dig deeper into its finances to pay for them. Alternate perspectives from a range of informed opinion, Howard Dean, Martin Feldstein, and the head of Harvard's Medical School show that the issue needs to be looked at closely and carefully and cannot be something in which CBO numbers can be trusted to tell the whole story. Especially when common sense, history, and informed opinion across a spectrum of thought advises caution, and fragile public finances also suggest caution. Howard Dean, former Governor of Vermont, says the health care bill is not real reform, and may do more harm than good. He says in a Washington Post article, December 17, 2009, the Obama health care bill does not insert competition into insurance markets, does not significantly reduce costs, and does not improve the delivery and use of health services. It was he says done with a political calculus and crafted for votes not real reform. Jeffrey S. Flier, Dean of the Harvard Medical School, gave the Obama health reform bill an "F" grade, saying in a Nov 18, 2009, WSJ article, that it was disingenuous to call this reform, Congress and the White House were simply deceiving the public. He said the bill will accelerate US health care spending, postpone most of the major health care problems, expecially the ones that drive cost, including the "fee for service" system and delivery of health care. He says in his discussions with economists and other health care leaders the opinion was unanimous that the bill will accelerate health care spending. He cites Massachusetts as an example, where access to care was expanded under the same dysfunctional system, and spending went up, and it doesn't work. Feldstein, who in early 2008 suggested proactive solutions to the mortgage debt crisis which were never adopted, says that the Obama health care law means higher taxes in the long run to pay for the $1 trillion cost of health care for the uninsured group over 10 years. Feldstein says that the Obama plan is to cut Medicare to cut spending, and will reduce the amount of medical services, as reduced spending comes from fewer services, not reducing payments to providers. And he asks if the cost reductions are weighted too heavily towards reduced services and not reduced payments to providers ,would this result in large cuts to services to affect the quality of healthcare for the 85% of the American people who are accustomed to a different pattern of healthcare. ...

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John Cochrane, professor at the Booth School of Business, University of Chicago points to the simple truths about U.S. healthcare- out of control pricing because of the pathologies created by previous laws and regulations. He points out that costs are high in healthcare because regulations keep them high. Supply of new doctors is controlled because Congress and the AMA made it that way with a cap on residency programs and AMA opposing the expansion of medical schools. In a system of open competition new hospitals and health care businesses would challenge old ones which is not happening in a regulated market with regulations working to limit competition for the firms already in the business and with the influence to limit competition. Insurance costs for major expenses in an open and deregulated competitive market without the regulations would be so much lower than todays costs that its likely we would not even need a mandate such as the one the Obama healthcare law imposes.

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This election is seen as a turning point for Britain. The Liberal-Conservative coalition has come up with a radical plan to cut spending and decentralize services in the areas of education, policing and health care. The plan is to cut the deficit quickly from 11% of GDP in 2009-10, to 2.1% in 2014-15. By comparison the outgoing Labor government's plan was to balance the budget by 2016-17. And the fiscal impact of Labor's budgets would have been 4% by 2014-15, compared to the Cameron government's looking at 6.3%, with larger and accelerated cuts in spending. It is something of a gamble by the Tory-Liberal government. If the severity of the cuts in spending stifle growth, then Plan B will be needed. The size of the cuts are not seen as feasible. With growing interest payments with the large borrowing by the government, and no real cuts in healthcare spending, departments delivering public services in Britain face cuts of 25% by 2014-15. With defense and schools limited to cuts of 10%- other departments would face cuts of 33%. According to the Institute of Fiscal Studies one way to reduce the severity of these cuts in department budgets, would be to find additional savings in the welfare budget. In June, Mr Osborne, the Chancellor of the Exchequer, announced 11 billion pounds in savings in this area (with half coming from using a different measure for inflation in calculating benefits). Additional savings of 14 billion pounds in welfare budgets, can reduce the size of the cuts needed in departmental budgets to 20%. One example cited is means-testing payments that go to the affluent as well as to poor people, such as child benefits, and cutting winter-fuel payments. Tories and Liberals agree on the need to decentralize government and services in the areas of schools, policing and the NHS. In schooling the idea is to give more choices to parents and children. Current schools can apply for academy status and new "free schools" will be run be non-profits, charities, churches, and parents. These schools will have freedom to set pay, select curriculum, and still receive state funding. In policing, the idea is to have directly elected police and crime commissioners for every constabulary in England and Wales. The elected commissioners would appoint constables and determine budgets and priorities. For the National Health Service the move is to give groups of general practitioners a significant role in the delivery of health care. ...

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Total public and private spending on health care in the U.S. will increase by 6.1% in 2014 compared to 2014 in a revised Commerce Department forecast. The total spending will reach $4.1 trillion in 2014 from $3.9 trillion in 2013. Some of the lower rise in spending than the earlier 7.4% forecast will come from 28 states opting out of Medicaid expansion under the health care overhaul because of a June 2012 Supreme Court ruling. Employers are trying to reduce costs and the public is reducing spending because of the recession. Less generous health plans mean users are paying more out of their own pocket, paying more attention to prices and even postponing care. Growth in health care costs is a about 3.9% a year since 2009 following the recession. The costs increase in 2015 by 5.8%, in 2018 by 5.9% and 2022 by 6.5%, according to U.S. government forecasts, because of enrollment in Medicare for baby boomers. This is still higher than the inflation rate of below 2%.

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A study by Dr. McCormick of the Harvard Medical School and professors at the City University of New York School of Public Health at Hunter College, shows that the anticipated savings from conversion to medical records may not materialize to the extent expected. This study of data from 1100 doctors of 28,000 patient visits shows that with access to digital records doctors actually increased the number of tests ordered- from 12.9% of visits without digital records to 18% of visits with digital records. For more advanced tests such as MRI and CT scan the rate was 70% higher. Dr. McCormick says this may be because the new digital technology may have made it easier to order tests.

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Biden sees his plan for American workers and families put together in the $3.5 trillion spending package that covers child care, education, healthcare, services, climate change proposals, infrastructure building, as a way to show that democratic governments can work for the people. After two decades when American workers and families were largely put aside in the nation's priorities during a tech driven and capital markets driven expansion that benefited large corporations, America is returning to its core concept of government by the people, for the people, of the people. White House officials say this is to be seen even in the program he put forward in his upset victory many years ago for the US Senate from Delaware. Because economic strength of America depends on a strong middle class, and strong working class, strong families, and underpins the world leadership role of America, even Republicans and hesitant Democrats, cannot give in to the current situation of doing nothing or too little for workers and families which weakens America. And at a time when its leadership role in Asia and Latin America, Africa is sorely needed. The size of the package in $3.5 trillion is because too little was done in the past in the mistaken acceptance of Reagan policies of no government role in the economy- surrendering this role of guidance entirely to the capital markets driven from New York, London, and Silicon Valley. The rise of China today, and also of Japan and South Korea, and of India as it plans for 2030 shows that government guidance of the economy is needed in global competition. Trade entirely driven by capital markets, without a role for government to emphasize national priorities in spending can lead to disastrous results such as we see today where manufacturing even in critical fields such as healthcare, semiconductor driven technology, entire parts of the economic structure are ceded to China and supply chains outside the US. German elections are also leading in the same direction with Social Democrats emphasizing national priorities in child care, education, healthcare, and delivery of social services, building of infrastructure. And the Greens emphasizing climate change. Merkel in Germany and in the European Union, her predecessor Schroeder, pursued policies of no government role in emphasizing and articulating national priorities, in a way that past US presidents have done, resulting in the CDU falling to 20% support in the September German elections. Across all parts of the world, from India, China, to Europe and the US, the focus is on government voicing the national priorities  and allocating funding instead of capital markets driven from London, New York and Silicon Valley, or capital markets in Shanghai or Mumbai, as the pandemic runs into its second year. ...

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Brazil held the Olympics and the World Soccer Cup, building new stadiums and living off the boom in oil and metals prices under previous governments. Today not only is there a lack of funding for infrastructure, healthcare, education and transportation.   This is now leading to lack of investment in healthcare services in a shocking way. The first full blown epidemic of yellow fever is hitting Brazil's cities of Rio de Janeiro and Sao Paulo. Officials fear that it will spread in an area that has 23 million people if it hits the slums where A.aegyoti mosquitoes are to be found in swarms. Rio and Sao Paulo are trying to tackle it by vaccinating 23 million people. Yellow fever kills about 3-8% of people affected. The economic crisis with lack of funds, and the political crisis that has affected Brazil with corruption scandals has led to a delayed response, according to experts at UCLA infectious disease center.  The disease is traced to loggers and monkeys in the Amazon region which usually remains contained in that region. SInce 2016 the lack of a strong official response has led to the crisis where monkeys carry it a mile a day all the way south to the Rio and Sao Paulo region. A effective government response would have included the use of media to educate people on the need for vaccination for all except newborns and pregnant mothers. Instead social media Facebook and You Tube spread the idea that the vaccination was dangerous, anti vaccine persons who normally got no audience trashed the vaccine. So that today public health authorites have to deal with this problem. The vaccination is highly effective and invented in the 1930's, was not started till November 2016, even though the spread southward from the Amazon region started in 2016. In fact says Dr Marquez, an expert at the University of Pittsburgh, only one in 100,000 gets a reaction and one in a million dies. He says compared to this 6% of 30 million people in the region affected could lose their lives, or  2 million deaths. ...

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Athenahealth, a provider of software for physicians, is intervewed by Jon Kamp about the efforts to promote digitization in physician's offices.