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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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Kathleen Sebelius, a former Governor of Kansas, pushed forward implementation of the Obama Healthcare Law as U.S. Health and Human Services Secretary, 2008-2014. She resigned in 2014 after IT problems made it difficult to use the government's Healthcare.gov website in 2013.

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This WSJ report shows how a record 4.4 million American workers resigned from their jobs in September 2021 alone. WSJ shows map of US with the states where this is happening marked with "I Quit." States with the largest quit rates have large share of employment  in food, restaurant, hotel and entertainment industries- Hawaii, Montana, Utah, Oregon, Colorado, New Hampshire, Louisiana. In the northeastern states the education sector which accounts for a larger share of employment the quit rate has risen at the fastest pace since January as shown in the Labor Department numbers. For years wages, benefits and working conditions in the food, restaurant, grocery store, hotel and entertainment industries, supply chain logistics, lagged behind, exacerbating inequality and widening the income gaps between working class Americans and the professional and other classes. Increases in minimum wages lagged behind the cost of raising families, rent and grocery bills. Professions such as nursing, children's education, critical to the nation's health were also left behind in wage increases as the tech boom rewarded different sectors in outrageous ways worsening the social divide and creating pools of income scarcity and income abundance in indiscriminate ways. The pandemic is changing all this. Workers in states with higher proportion of workers in these sectors of the economy are saying "I Quit," as they seek better opportunities elsewhere and better working conditions. The checks to working class Americans in 2020-2021 as aid for the pandemic, the child credits, investments in affordable housing, child care, early childhood education, and other aid in the Biden Families and Workers plan are giving workers for the first time in decades the right to choose better working conditions and incomes over worse working conditions and incomes that were set without regard to their role and contribution to the welfare of the whole country and people.  After the lockdowns in the northeastern states, States such as New York, Massachusetts, New Hampshire, Rhode Island,  with higher vaccination rates and rebound in the economy are seeing higher job openings. This is making it possible for workers in the northeastern US to quit jobs in educational services and other sectors  for better paying jobs, better working conditions, remote work options, and improved work-life balance. ...

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Two law school professors at Fordham University, Kysar and Sugin, say the Republican tax bill is extreme because it was not based on working with Democrats. As a result not a single Democrat supported this tax legislation. The problem- when the Republicans lose their majority in Congress- a serious possibility after the loss in a Senate race in deep red state Alabama- the whole issue of tax legislation would come up again. This is not without precedent as the Democrats won the presidential election in 2008 and Republicans made a sweeping victory in Congress in 2010.This is why Senators Casey and Wyden (Democrats) and Orrin Hatch (Republican) head of the Finance Committee stated on the floor of the Senate on Dec. 19, 2017, that the next time and in future both parties need to engage in real discussion on taxes. The lack of serious discussion on the health care bill passed by Obama in 2008 has created some of the same problems today that this tax bill passed in a similar way without discussion with the other party is likely to face by 2019. No one needs to look further to realize that the political system is failing in its job of grappling and solving the nation's problems. Kysar and Sugin say this bill is like the 1981 tax cuts skewed towards high income Americans which failed to generate economic growth as intended an led to a swift reversal with tax increases in 1982 and years that followed in 1983, 1984. President Obama failed to address tax reform after appointing the Bowles Commission and not taking up its recommendations to reduce deductions. Another effort at changing the system was made without serious debate, a kind of Republican response to the way Democrats passed the Affordable Care healthcare bill in 2008. Real changes to update the tax laws may be put off till both parties can wrap their hands around the problem together. ...

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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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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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This editorial in the WSJ raises questions about Chief Justice Roberts' written majority opinion, and says Justice Scalia's comment about SCOTUScare should be replaced with the term RobertScare. It says Justice Roberts has emerged twice as a "political" Justice in the way he has interpreted the law in this case.

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One in six dollars generated by the U.S. economy goes to pay for health care, almost twice the average for rich countries. It hurts America in many ways; by being a burden on the taxpayer when it comes to Medicare and Medicaid paying for the poor and the elderly, on companies being one reason GM went bankrupt, it eats up federal and state budgets, rising costs make any form of future coverage for all unsustainable, and it robs other priorities such as infrastructure building and other national scale investments. The Economist says that if it had to design a system from scratch, it would go for a system based mostly around publicly funded health care. For the uninsured the solution of an employer mandate is now well accepted, so this is not an issue. What is an issue is how to make the new system affordable? Here the Economist says that whether in stages or in one move, the tax deductability of employer paid health insurance, which is costing the U.S. government $250 billion ayear, has to go. It is necessary to remove this deduction, and its something all interests involved will have to swallow, as other savings are smaller and will not be adequate. The deductability of insurance makes the true cost of insurance transparent, so it supports gold plated insurance. This does not make cost control the pressing priority it needs to be. So the deducatability of employer paid health insurance hurts both ways. The other necessary action is in the area of moving out of the current culture where most doctors work on a fee-for-service basis, where the more tests they prescribe or procedures they perform the greater their incomes. This acts as a perverse incentive, and has aruinous effect in mushrooming health care costs in America. Cutting back on unnecessary tests and procedures, and prescriptions , would save 10% to 30% of health costs says the Economist. And it says this has been proven with the Mayo Clinic in Minnesota and Kaiser Permanente in California showing that cutting back doesn't hurt care and outcomes., so much so that cutting back would occur along with improved outcomes. But Americans with employer paid insurance just take things for granted as its not much out of pocket expense for them. THis creates the lack of a force for controlling costs even as employers are shouldering abigger and bigger burden, and the employee who thinks he is doing fine actually is seeing more of his salary dollars going to pay for his health insurance. In a way the consumers of health care are stuck with the perception that they are not somehow paying for these mushrooming costs and too manytests, procedures and prescriptions. This perception leads them a false sense of comfort with the system they are in, and a fear of something new fanned by the medical lobbies, that any change will impact users negatively. This makes the whole discussion on health care or the process of finding solutions to become an exericize in which terms like "rationing" and "choice" play a distorting role. ...

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State based exchanges in New Mexico, Oregon and other states have experienced difficulties setting up and running the exchanges. Many states have turned to the federal government to operate the exchanges.

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Chinese president Xi's determination to make good on the slogan "Housing is for living, not for speculation," by imposing a property tax on homes in 30 cities, is facing resistance within the Communist party and from local governments. Mr Xi hopes to squeeze out the excesses of the adoption of capitalist market systems in China since 2000. China's government opted to get feedback on this idea and the feedback is largely negative forcing the government to scale it back and look at other alternatives such as affordable housing to make home purchases accessible.  Some reasons for the pushback are that it is becoming a social stability issue and risks alienating officials within the ruling party and homeowners. The fact is that 90% of urban Chinese families own their homes and housing related industry makes up about a third of China's output. Also significant is that 80% of China's wealth is tied up in real estate. What could happen is that if housing prices drop in China urban consumers might cut back on spending because they feel poorer. Party officlals advised against introducing property tax in 30 cities. Now it is scaled back to ten cities, and a new law could take till 2025 to introduce property taxes in the whole of China. Cities that are likely to be used for the property tax now are Shanghai, Chongqing, where an annual charge is levied on second homes since 2011. Cities added to the list would be Shenzen, Hangzhou, China has financed much of its industrialization through land sales by the Communist local governments in a country where land ownership was with the national Communist government after the revolution in 1949.  Mr. Xi wrote in Qiushi party journal that "we should actively and steadily promote the legislation and reform of real estate tax, and do a good job in the pilot work." Local communist governments get about one third of their revenues from selling land to property developers, and they are anxious that a tax on real estate would make demand and price for the land they sell to drop drastically. To get some idea of this- the local governments had $1 trillion in revenues last year. ...

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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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Professors Gluck and Graetz of Columbia Law School discuss the presumption of severability in case the Obama health care law is declared unconstitutional by the U.S. Supreme Court. Severability would mean some parts of the law could be left intact if it is declared unconstitutional.

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Ezra Klein on the three questions on which the Supreme Court will decide after three days of hearings on March 26-28, 2012- the Anti-Injunction act, The Individual Mandate, and Medicaid Expansion. Related to the Individual Mandate question are Severability issues.