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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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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 health care system is designed to encourage procedure based specialist practices and discourages the patient understanding education and monitoring that occurs with a well designed preventive family physician practice. As a result a patient only spends 30 minutes ayear on average with family physician compared to one hour in other developed nations. In the USA there has been a steady decline in the level and quality and extent of family care and the close one on one rapport with well trained family physicians who enjoyed their work and understood their patients and kept up with their health conditions and provided good and regular advice on these conditions. There is no money in this care as a result first you provide an environment where a whole range of medical conditions can flourish and expand, and then you hit them with a whole series of tests to rule out specific medical conditions. It is a perfect way to expand the testing and let testing flourish, so it would appear that if someone had wanted to start with a goal of letting testing proliferate unhindered then this would be the perfect way to design it. ...

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Slowdown in drug sales growth in USA and Europe. Top seven emerging markets will account for 34% of global sales growth upfrom 7% in 2000. And the USA accounted for 40 to50% of growth in global pharmaceutical sales each year early in this decade, in 2009 the sales in the USA will account for just 9%. Forecasts and figures are from IMS consulting firm. USA sales will rise only 1-2% if at all, while emerging markets will grow by 4.5% to 5.5%. With the economic troubles American consumers are less likely to fill prescriptions and insurers are not covering new drugs and favoring generics. Intense competition among generics drug makers is reducing prices. IMS predicts that the global generic market will grow by 5 to 7% in 2009 to $68 billion, slowing from double digit growth. This is from total sales forecast for pharmaceuticals globally of $830 billion.

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Copies with slight changes to extend drug life with new brand names- Clarinex for Claritin, Nexium for Prilosec, Paliperidone for Risperdal being the latest in this new marketing strategy of drug companies to extend the life and sales of a successful drug. The drug companies try to market the copy drug as a significant improvement, which is what J&J is doing with Paliperidone. Experts are skeptical. Pricing of the generic versions of Risperdal or its copy will be much less expensive. Cost is a sensitive issue. About 15% of Risperdal's $1.35 billion sales were from Medicaid, generic substitutions offer potentially large savings. Meantime J&J did not do clinical tests between Risperdal and Paliperidone, the tests with 1600 patients compared Risperdal with a sugar pill. A psychiatry Professor at Duke and another professor at NYU are skeptical of J&J claims for Paliperidone. United Health shows savings of $150 million by using generics instead of Nexium, so managed care payors will tread carefully....

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Obama cites "Seneca Falls and Selma and Stonewall" in his second inaugural address after failing to push strongly enough to address poverty and civil rights, housing foreclosures impact on minorities, and immigration during his first term. Stevenson says the address was filled with King's "urgency of the now," in pushing for progressive values in an unabashed manner. Freed from the constraints of the first term Obama senses the urgency of the moment if he is not to lose the opportunity to have contributed to the march of progressive values in America during his term as president. A cautious president feels the urgency of the progressive spirit that marked his early years, his first book, his work as a community activist and Illinois legislator; if all this is not to be lost in the burdens of the presidency, the pressures of politics, the fundraising machinery, election manoeuvring and vote getting that secured the presidency.

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Seib points to the part of the president's inaugural speech that said action must be taken even if victories are partial, that the debates over the role of government could go on for all time, but action however imperfect needs to be taken in this time. There is a sure willingness to engage in more partisan fights with Republicans and a broader list of issues from climate change to immigration, gender equality and curbing guns. The diffusion of the pent up purposes- pentup by the first term economic and healthcare issues- and the short time during the second term of 2 years to accomplish this, adds to the urgency for the president Obama.

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The National Childhood Vaccine Injury Compensation Program protects vaccine makers from much of the litigation risk faced by pharmaceutical manufacturers. It limits compensation for death to $250,000. This special vaccines court is called Office of Special Masters at the U.S. Court of Federal Claims. This may be one reason for Pfizer's willingness to pay $68 billion for Wyeth which is amaker of childhood vaccines. Vaccines will generate $21.5 billion in sales by 2012, according to Sanofi-Aventis. Vaccines are biologic products that can't be copied. Wyeth's Prevnar is designed to protect children against 7 strains of pneumococcal disease. It has sales of $2.7 billion projected to grow to $5.5 billion in 2015 according to Sanford C. Bernstein & Co. Vaccines have driven huge reductions in childhood diseases, and the Act is designed to potect makers of vaccines, who suffered from excessive litigation in the 1980's.

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The Economist quotes experts saying that drug innovations would not be affected by price controls on drugs. Pricing reforms can accomplish the reverse, spur innovation by doing as Britain and Germany are doing- pioneering comparitive reviews of drugs effectiveness and cost-benefit analyses aimed at reimbursing firms for new drugs based on their performance. Sanford Bernstein, a financial advisory firm, says in its study that a 20% reduction in what Medicare pays for drugs would not kill off innovation, it would reduce earnings per share of big pharma firms by 3-8%. As drug research is now done in many countries, and its a globalized industry, innovation is not likely to be automatically affected by price reductions in one country like the USA, according to Alna Garber of Stanford University and Patricia Danzon of Wharton Business School.

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As Indian pharmaceutical industry sees drug testing in India as an opportunity, conditions for obtaining the best results are being established by taking necessary steps. With ashortage of experienced people to run drug trials, Indian government has stepped up training, setting up partnerships with the U.S. FDA, Health Canada, the World Health Organization, and other similiar organizations, The emphasis should be on credible dat and the safety of subjects says A.K. Pradhan, India's Assistant Drug Controller. After the death of an infant in a Wyeth Pharmaceuticals drug testing effort, the Drug Controller of India though supportive of Wyeth has raised certain issues that Wyeth is addressing.

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Walgreens is changing its growth model to add the business of Health and Wellness buying two companies I-trax Inc. and Whole Health Management which run 350 health centres at corporate offices. Pharmacies will be added to these centres. Its targeting 7600 office sites with 1000 or more employees that could use a health-care center. Its competitors CVS and Walmart are going into managing employer drug benefit programs, with Walmart's selling point being reducing costs of paying for prescriptions for employers.

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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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This leader in The Economist reviews an essay in the magazine's October 8-14th, 2016 edition by U.S. president Obama. In it Obama points to the unfinished tasks of his presidency and what comes next as tasks to be done for the U.S. economy. The Economist points out the problems in the 2016 election campaign where there is a lack of discussion of economic issues as a serious problem. Obama lists as priorities efforts to improve conditions of people left out in the recovery, reducing inequality, offering more job opportunities, and increasing productivity.

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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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With 5.7 million jobs lost since December 2007 fewer people are paying payroll taxes to support Medicare and Social Security says Labor Secretary Solis. As aresult Medicare will run out of funds by 2017, 2 years earlier than predicted last year. Medicare and Social Security issued their annual report yesterday, suggesting the nation cannot afford the cost of Medicare at the rate of current expenditure growth. Social Security will run out of money by 2037 four years earlier than predicited before. The only way to keep Medicare solvent says Mr Geithner is to reduce the rate of growth of health care costs.

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The new Dutch Health system that went into effect on Jan1, 2006, and is based on Stanford university prof Eindhoven's idea of "managed competition." What the Dutch experience holds for the USA as states like massachusetts look at mandatory universal health coverage on a private basis and for the US as a whole as the present system appears to be coming to a close.