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The coverage of the Republican healthcare bill and how it affects the elderly, and people on Medicaid, people in rural areas, is likely to have changed public opinion in the U.S. about the necessity of ensuring all Americans have health coverage. The Pew survey cited here in this NYT report by Zernike and Goodnough was done in Jan 2017, and shows a shift. The shift would be much higher today after people look hard at the consequences of what were simply hypothetical positions or ideological positions taken without looking at consequences in daily living. On Medicaid that opinion by July 2017 compared to Jan 2017 has shifted 10 percentage points for Republicans to 53% who think Medicaid is important to them and their families, according to Kaiser research. There is stronger sentiment about people having benefits taken away.  [article-55059] The opinion has shifted to where people see that coverage is important and people should not have coverage denied or benefits taken away from them. Opinion remains strong in favor of changes to reduce the high premiums, but not to replace the existing health benefits and law with no law at all to replace it. That leaves 20 million more uninsured according to the Congressional Budget Office. Changes have to be constructive is the popular view today,  and this requires dialogue between Republicans and Democrats- which has not taken place. ...

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The tech boom bust since 2000 that has hurt America and Europe and which also laid the foundations for the loss of manufacturing and technology to China, ceding American leadership and critical advantage, is shown here in the WSJ. The role of the finance sector  is explained here. That has added one more factor to the factor of endless wars in the Middle East, where American and European investment in healthcare, education and new infrastructure was somehow diverted away, and much of America's and Europe's resources wasted- or not turned to the benefit of the people of America or Europe.  One financial firm that rode the tech boom to the hilt finds itself with unacceptable losses except in a severe recession. Tiger Global Management was using tens of billions of dollars from pensions, endowments and rich clients riding on some of Silicon Valley's hottest stocks.  With the plunge in tech stock values including startups in which Tiger pushed into aggressively now facing large losses after hyper valuations, Tiger's hedge fund which managed $23 billion at the end of 2021 was down 52% in 2022. Another of its funds that managed $11 billion has lost 62%. WSJ says this wiped out two thirds of the gains Tiger has made in the tech stocks since its founding. In addition large writedowns are expected on its venture funds valued at $64 billion at the end of 2021, says WSJ.  WSJ says cheap money (money somehow diverted from infrastructure and funding manufacturing in China instead of the US now goes by the misnomer cheap money) reshaped Silicon Valley in the last decade, as pension funds, rich investors and celebrities turned to well connected money managers such as Tiger to put money in tech stocks and startups. This WSJ report says compared to Sequoia Capital and an earlier generation of venture companies Tiger Global is simply not interested in management of companies it invests in, taking a broad brush approach, using Bain Capital for research, and trying to haul in a large load of fish like trawlers at sea hoping for some companies to make big gains. Many pension funds such as Calpers California's public pension fund invest in Tiger with a $400 million investment. WSJ also reports that Tiger Global's venture funds do not reflect the realities of the tech business as venture stocks will reflect the drop over 2022 and 2023, including its ByteDance Chinese tech investment which will need larger writedowns. Tiger has also not hesitated to get into cryptocurrency which has loss of about $1.5 trillion dollars. It is of interest to note that Julian Robertson, hedge fund manager of the 2000 period (when Clinton-Bush were US presidents) who ran Tiger Management provided the impetus for Mr. Coleman, then 25 years old, for the start of Tiger Global. Julian Robertson closed his fund in 2000 during the dot com bust. Coleman hired a Blackstone analyst and started on the next cycle of tech with social media platform Facebook now Meta, followed by China's JD.com as investments in a new China boom were started. The end result is that during a period of Middle East wars under Bush and Obama, and building dependence on Russian oil and gas supplies under Schroeder and Merkel, China was the gainer as the US and EU lost much of its manufacturing and technology to China. During this period US and Europe neglected investment in infrastructure that would benefit the people of America in ease of living and quality of life. Just as money was wasted in wars much of the tech investment was wasted. The companies that added value over time were started long before and relied on sales growth and new products that revolutionized their field such as Apple with smartphones that started well before the nineteen eighties, Amazon with logistics and its own style of management, Microsoft from an even earlier era. Tech monopolies Facebook, Google, and others would not be missed much in terms of real progress for the people of America. The cost is many decades of ceding manufacturing and technology advantage to China by US and the EU led by Germany. China 2030 and the war in Ukraine with China's support have shown how fragile the foundations have been with weak political leadership and a finance sector running backwards in terms of America's and Europe's strengths in new infrastructure, better healthcare, services and education for the people of America and Europe. Leaving it to the Biden administration and a new coalition of Greens and Scholz in Germany to begin the task of rebuilding America and Europe on strong foundations, including the dignity of the workers and families, that makes who we are and what we believe in, and why the free world believes in us. ...

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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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A critical part of the Affordable Care Act is the setup of marketplaces or exchanges to let people without insurance buy individual health plans. Some states setup their own exchanges, and some states let the federal government step in and run them. To help the lower middle class and poor the Act provides health subsidies to buy insurance in the exchanges, and 85% of customers in the exchanges qualify for this benefit. The U.S. Supreme Court voted 6-3 in 2015, compared to a tight vote in 2012 on the Affordable Care Act, to maintain the health subsidies. Justice Roberts wrote the majority opinion, saying "Congress passed the Affordable Care Act to improve health insurance markets, not destroy them." Justice Scalia dissented calling it "interpretive jiggery-pokery." Justices Clarence Thomas and Samuel Alito Jr. dissented. Voting in favor were Justices Anthony Kennedy, Ruth Bader Ginsburg, Stephen Breyer, Sonia Sotomayor, Elena Kagan, Justice Kennedy dissented in the 2000 case. The challengers petition to the courts was based on a reading of phrases in the Affordable Act which had not occurred to the writers of the law. The reading suggests only people enrolled in state setup exchanges are eligible for subsidies. If the Supreme Court ruled in favor of the plaintiffs the 6.4 million Americans who are enrolled in the federal exchanges would lose the subsidies provided under the law and lose health insurance. And the economic foundations of the Affordable Act would be undermined with insurance companies required to provide insurance to all regardless of pre-existing conditions and subsidies removed, leaving the companies with sicker pool of customers resulting in destabilizing the exchanges and higher premiums. The court ruled in favor of an interpretation that is compatible with the whole law and the intentions of the statute to help the middle class and the poor buy health insurance. The chaos in the insurance markets that would result in going with the plaintiffs because of a careless writing of a phrase, was uppermost in the majority's mind. Chief Justice Roberts emphasized this, saying- "The statutory scheme compels us to reject petitioners' interpretation, because it would destabilize the individual insurance market in any state with a federal exchange and likely create the very 'death spirals' that Congress designed the act to avoid." This case originated with 4 plaintiffs from Virginia who challenged the IRS regulation that said subsidies were allowed regardless of whether the exchanges were run by the state or the federal government, arguing that this was at odds with the particular phrase in the law that was ambiguous about federal exchanges eligibility for health subsidies. Judge Roger Gregory of the Fourth Circuit Court of Appeals in Richmond, Virgina, ruled that the phrase was indeed ambiguous, but the IRS was owed deference in its opinion. Chief Justice Roberts made it clear that this was not a case for the IRS, saying "it is instead our task to determine the correct reading." ...

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The Republican House health care bill AHCA  keeps some some of the more popular parts of the Affordable Care Act such as not taking pre-existing conditions to deny insurance, keeping children covered on parents insurance till age 26, and increase contributions to Health Savings accounts. It is different in that the expansion of Medicaid at 138% of poverty rate threshold is rolled back. Age is used for tax credits instead of income, hitting those approaching Medicare age harder. The maximum charged to older people is now set at  5 times compared to 3 times what young have to pay. In general the Republican bill is seen as targeting the elderly to keep premiums down. The elderly on low incomes are hit hardest. Fox News O'Reilly Show showed the host questioning House Republicans, citing the CBO estimates that elderly on low incomes may have to pay as much as $14,000 a year for insurance making it basically unaffordable, and 52 million Americans would be affected adversely. Large companies are no longer required to offer mandatory health insurance under the new bill. Conservatives from Freedom Caucus wanted to see the essential areas of benefits covered by the law limited to fewer than the ten areas in the Affordable Care Act. The ACHA Republican bill leaves to states to determine what are required essential benefits. At one point maternity benefits were to be dropped but this was changed to let states decide. As a result the bill is 33 votes short of the number needed for passing the house in March 2017.   Neither the Democrats Affordable Care Act or the Republican House bill of Speaker Ryan do much to tackle the real problem- the absolute amount and increases for health care dollars for treating each disease in the U.S. compared to European and other countries. As a result health care has become more of a partisan struggle between the two parties than a real effort by all to overcome the problems that have to be tackled. Republicans want to see premiums drop and keep the burden on the deficit down- but with the level of U.S. health care costs disproportionately high compared to Europe and the rest of the world the arithmetic is tough and ends up leaving out vulnerable groups such as the elderly on low incomes, thus making the whole proposition prone to fail. For the same reason the Democrats failed to keep premiums down with a wider safety net leading to calls for repeal of their version.   ...

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NYT reports show the Republican health care bill AHCA 33 votes short of passing the House and likely to fail. Conservative Republicans were looking to whittle down the safety net in the Affordable Care Act, and moderate Republicans could not stomach the whittled down bill removing guarantees of essential benefits for instance. The basic problem- no real consensus among Americans about providing health care to all Americans, and no real solutions possible as long as there is acceptance of disproportionately high levels of medical care costs for treating each disease in the U.S. compared to Europe and other countries.

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The U.S. House of Representatives votes to repeal and replace the Affordable care Act 217-213. Moderates were won over by an addition of $8 billion  to add coverage for a popular feature of the ACA that covered people for pre-existing conditions.  The bill that passed gives credits of $2000 to $4000 a year, depending mostly on age, upto $14,000 for a family. Credits are reduced for individuals making over $75,000 a year or families making over $150,000. There is no mandated insurance coverage. This trims the federal budget deficit, yet also is expected to keep 24 million more Americans without health coverage after 10 years. The bill now goes to the Senate where moderate Republicans are worried that this may increase premiums for older people, one of the drawbacks of the earlier version of the House Republican bill.

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This is an exceptionally humorous operating room story of Dr. Trump and Dr. McConnell by Kristof of the NYT. Sometimes humor tells the story- and Kristof does this using a story of a surgeon president Trump in the operating Room trying to address the concerns of the patient Janet, as he keeps telling her she needs a new heart with great benefits, great benefits, before she implodes or goes down failing. Flat out take the old heart out even if a replacement hasn't been found, believe me great benefits the surgeon tells her, just that the patient just isn't getting convinced as its happening to her. The analogy is with replacing a health care plan, not just the Obama plan, any plan without something to take its place. For a few days before this article by Kristof, the Republican effort to repeal the Affordable Care Act without having a replacement was presented as a good idea. Janet is like the three Republican women- Collins of Maine, Capito of West Virginia, and Murkowski of Alaska who wanted to keep the heart they had till a replacement was found, against the surgeon Trump's advice. In a way it is about politicians in the last decade who never had any discussions as they rushed through with their own agendas, as the Republican and Democratic health care plans were rushed through Congress with relatively little participation and debate to hear all viewpoints. ...

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With the rushed approach adopted by the Trump administration not enough consideration was given to winning support in the House from 25 conservatives in the Freedom Caucus. Without their support the bill cannot be passed in the House of Representatives. The fight also includes one over what are essential health benefits including whether  maternity care would be included. As a result some moderate Republicans are also expressing opposition on the grounds that less people will be covered and fewer benefits will be provided under the Republican House plan called AHCA. President Trump has not involved himself in the details, and the bill comes very early in the first 100 days, leading to the perception that health care has become a partisan conflict without really grappling with the problems of high cost of health care and creating a solution that all can support. Democrats are seen as having made the same error early in Obama administration's first term. President Trump sees this as a much needed win with a drop in his approval ratings, making this even less of an effort to come out with a good plan.  ...

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The Congressional Budget Office analysis of the Republican healthcare plan advocated by Mr. McConnell, Senate Majority leader, is that it would add 22 million uninsured if implemented. That plan ran into opposition from Republican Senators Collins, Capito, Murkowski, Paul, and Moran, and lacked enough support in the Senate. All Democrats opposed it and with the thin majority Republicans were divided. By taking away some benefits given under the existing Affordable Care Act the plan hurt the elderly and low income people, making some Republicans listen to their constituents in home districts and not the Republican leadership. The NYT profiled two in particular who astonishingly in a sign of today's strange politics were the only ones publicly holding townhall type meetings to hear the views of people in their voting districts- Susan Collins of Maine and Jerry Moran of Kansas. Both senators were listening to rural communities and Moran stated his opposition with the words- "I am a product of rural Kansas." With it the nation takes a breather and the message goes out that it is best to listen first and then to seek middle ground, not do what both parties Democrats and Republicans did in 2009 and 2017- rush serious legislation through without support across party lines and without serious discussion.   ...

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Polly Lower quit her job to take care of her granddaughter, and Eddie Gonzalez-Novoa quit a $88,000 job to help a nephew who is a cancer survivor setup his startup video-gaming and social media site, and provide childcare for his granddaughter. They are 2 examples of the equivalent of 2.5 million workimg people the Congressional Budget Office estimates will reduce hours or quit jobs and take the government subsidies to lower income earners for healthcare insurance in the U.S.

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Ann Matthews describes how the U.S. Supreme Court ruling on the Obama health care law affects 4 managers in the health care industry and U.S. businesses.

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This NYT editorial on June 26, 2015, says the arguments of the plaintiffs before the U.S. Supreme Court for the Affordable Care Act were specious, based as they were on a reading of four words phrase in the Act leaving ambiguity about what exchanges were covered by health care subsidies. It says the plaintiffs with strong emotions on the subject decided to pull their argument out of thin air. That only one Justice acted as the swing vote, Justice Anthony Kennedy, shows the Supreme Court like the rest of the nation is not above emotion- Justice Scalia called the 6-4 decision based on "jiggery-pokery" and not "honest jurisprudence"- and needed Chief Justice Roberts to provide the larger view in 2015 as he did in 2012.