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Comparative effectiveness research will be conducted to evaluate what is the best treatment for any ailment or disease or health problem under the $1.1 billion allocated for this in the Stimulus Plan. What are the alternative methods of treatment, what is the effectiveness of each treatment, what are the comparative costs and so on. Is it better to treat neck pain with surgery or acombination ofphysical therapy, exercize and medications? If there is ablockage of arteries in the lower leg and leg pain, how does drugs and watchful waiting compare with surgery? For chronic heart failure how does home monitoring of blood pressure and weight and exercise in addition to medications provide an alternative route as opposed to just medications. Dr Fisher of Dartmouth Medical School cites these as examples of questions that can be asked in comparitive effectiveness research. The money will be available to the Health and Human Services Department and will be used over several years. About 15 federal employees will form a council to coordinate the research and advise President Obama and Congress on how to use the money. In 2007 the US spent $2.2 trillion, or 16% of GDP, on health care, and the Congressional Budget Office says it will grow to 25% of GDP at the rate its growing by 2025 if left to its own devices. ...

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Of the people asked the question "what issue do you see as the most important for health care" 44% in a NBC/WSJ poll said they considered Cost as the biggest issue, and 37% said that they considered the Uninsured as the biggest issue, 11% said quality of care was the biggest issue. The President is focussing on cost as he develops the health care plan. He is also saying that to provide health care for all and cover the uninsured without controlling costs would break the bank. Another thing that the White House shows it has learned from previous failed attempts, is that it is doing this with an open Health Care Forum with participation of different sides in the health care discussion. Clinton's effort in 1993 ran into problems because it was developed secretively, and without much discussion, and little effort to get different people's views. The previous attempt also waited too long after the election, and this time the President is moving quickly when he enjoys large popular support. Its also true now that there is serious concern especially in this downturn of what a threat spiralling costs of health care are becoming to the future prosperity of the American people. This time the leaders in Congress are setting an aggressive schedule to get health care palns legislation on the floor by June and get a floor vote in August 2009....

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Laffer says there is a big gap between the cost of health care and what people actually pay, which keeps cost escalating as there are no pressures from users of services to economize or bring reductions in the prices. But Laffer offers no effective solutions either his patient centred approach to health care reform does not address the problem that employers are paying for health care for the large part and these are not taxed as benefits leaving the employee free to load up on services and ignore the cost, which works just fine for the health care providers who increase revenues and profits- also called cost escalation upto the point now reached where the nation can no longer afford it.

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Greg Ip of the WSJ cautions about thinking that the GDP growth of 3% is likely to be achieved with the Trump plan for a corporate tax rate of 15%. He says evidence from Britain and Canada- Britain reducing the tax rate from 30% in 2007 to 19% today, and Canada from 28% in 2000 to 21% in 2004- is disappointing. In Britain the increase in GDP averaged about 0.1% a year. Business investment increases with cut in corporate taxes, and the U.S. corporate tax rate is higher than other advanced countries such as Germany, yet GDP growth includes other factors, such as the business cycle, demographics, productivity growth, aging, technology, regulation, says Ip. It is better if the tax cuts are spread broadly over the population, and tax cuts are offset to a greater extent by savings in other areas, and that tax cuts promote productivity boosting investment, to create enough of a surge in growth above 2%.

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Leonhardt says that there is little reason to think that the flatter rates are better always. With the need to finance Medicare and health care for all, the government can use the extra dollars from taxing the very wealthy, the very rich in different tax brackets. The top bracket in 2008 started at 357,000, and you paid 35% whether you made 400,000, or $4 million, or $40 million. So basically the upper middle class was lumped in with the extremely wealthy. And considering the cost of college tutions for 2 or 3 kids, the upper middle class is only middle class. It makes sense not to lump the two together. Considering that there has been a lot of wealth accumulated at the the very high end, it would also reduce inequality, generate tax revenues for health care, and not have much effect in the incentives for generating economic growth. It is something he says the Obama adminisstration may and should consider.

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The European Union Commission says Ireland must recover 13 billion euros in back taxes for giving tax preferences to Apple that are against EU rules. The EU Commission says Ireland allowed Apple to pay a corporate tax rate of 1% on its European profits in 2003, and .005% in 2014. The EU Commissioner says the use of Ireland as the place where Apple pays taxes on operations in Europe has no base in reality, as most profits are earned in other countries outside Ireland. Taxable profits of Apple "did not correspond to economic reality," according to Ms. Vestager, the EU Commissioner.  In the current environment where political upheaval is unsettling the democratic process in the U.S., Britain, Spain, France and Italy, as well as in Brazil and other countries in the developing world- because of deep recessions, and efforts to cut the deficits with deep cuts in state spending including in education and healthcare, basic services- the moves by companies to reduce taxes to these absurdly low levels such as .005% when other companies in the EU are paying 12.5%, is becoming increasingly unpopular. As pointed out in this BBC News article this sounds like the way Carnegie, Rockefeller and Vanderbilt operated during the late 19th century, and were seen as operating in a manner that was above the law. Janet Yellen pointed out at a Boston Fed Conference on inequality in Oct 2014 that the bottom half of the distribution or 62 million households in the U.S. in 2013, had a net worth of about $10,000, One quarter of these households had a net worth of zero dollars. The working class and blue collar workers in the U.S. provide much of the support at Trump rallies. Younger college educated people support Sanders, because of the situation of the working and middle class in the U.S., and a similar situation exists in Europe. It is for the sake of the democratic process and delivering services in education, healthcare, and other basic areas to all, that companies small and large need to pay their fair share of taxes, regardless of size, influence, or technological advantages. Today this is is seen by most leaders who draw public support as the right way forward for the U.S., Latin America, Europe and Asian countries, including proper allocation of resources to best serve the needs of working people. For example the 13 billion euros is equal to all of Ireland's healthcare budget, and 66% of its social welfare budget.    ...

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The inflated costs for spinal surgeries at some hospitals in California. How surgeons, doctors, consultants, distributors and hospitals operated in a flawed system to make revenue gains through overbilling, and focus on increasing the number of surgeries performed.

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Glenn Hubbard, Professor at Columbia University and Bush adviser who helped design the Bush tax cuts, has an uneasy sense about the tax cuts today. He says the tax cuts have been undermined by years of deficit spending. The Bush tax cuts expire Dec 31st 2010 in the USA if Congress does not act. Macroeconomic Advisors estimates that letting the tax cuts expire will take 0.9% off the growth rate. Nobel Prize winning economist Paul Krugman prefers to let the tax cuts expire and provide more help to state and local governments to preserve jobs that are being lost due to budget shortfalls. But becuase of the political climate he prefers to let the tax cuts go on for a limited period. The Obama administration may decide to continue with the tax cuts rather than fight the serious battles for deficit reduction, after spending much of its political capital on health care reform. Hubbard also thinks in the current situation its best to keep the tax cuts even with the concern for the deficits. He says the spending during the Bush administration, especially the Medicare prescription drug benefit, which is estimated to cost $400 billion from 2004-2013, was a major problem. The incentives to business and investors for productive effort in the Bush tax cuts is uncertain, if it becomes clear that the price for these cuts is higher taxes later on to cover growing deficit spending. Hubbard does not see any serious action on the deficit till the next Presidential term and sees it better to keep the tax cuts till then, when some serious discussion can take place....

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Feldstein says that for the 85% of the people who have healthcare the Obama proposals are not a good deal. The Obama proposals mean higher taxes in the long run to pay for the $1 trillion cost of healthcare for the uninsured group over 10 years. This lower income group has no coverage despite the $300 billion Medicaid program. Feldstein says there surely must be better and less costly ways of getting this lowincome group healthcare. Raising the top income tax rate to 45% from 35%- as a result of letting the Bush tax cuts expire and adding aproposed health surcharge on higher income individuals- would actually lower revenues for the government, as it would change behavior of high income individuals in ways that lower their taxable inome. The result is higher deficits and higher taxes when even without this large deficits are projected for the future. How to slow the rapid growth in healthcare spending? The Obama plan is to cut spending on Medicare. Feldstein sees the govenment's effort aimed at reducing the amount of medical services, as reduced spending comes from fewer services, not reduced payments to providers. Will this result in enough of acost reduction to make the system work. And if the cost reductions are too heavily weighted 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% who are accustomed to a different pattern of healthcare, even though it is structured to allow cost escalation. Feldstein offers no solutions to the problems of cost escalation except to suggest that the Obama plan does not really tackle the cost escalation issues directly with providers, and instead burdens the national finances to an extraordinary degree. And the need for apause and reflection....

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WSJ reports that the former president's supporters will rally to his side but swing voters might be repelled by this latest legal controversy including the context in which it happened that of a sordid affair. Mr. Trump built his support base out of two mistakes of president Obama, his neglect of rural America, and neglect of American manufacturing. And of the mistake of president Bush in pushing America into two wars in Afghanistan and Iraq that put money into wars with no productive purpose that needed to be put in rebuilding America's infrastructure. Others could have done this, Mr. Trump aggressively pushed ahead and found himself first. President Biden has closed the chapter on the wars by ending them, he has also closed the chapters of neglect of American manufacturing and put working families and America at the top of his agenda at every point. And as he did at the State of the Union address in 2023, made it personal by reciting what his father has told young Joe about standing up for working families. Biden's abilities rival that of president Lyndon Baines Johnson, who had as much experience in the US Congress as Biden, and delivered the passage of Medicare and Social Security for all Americans. Biden has done something that ranks similar with trillions of dollars for the Inflation Reduction Act, CHIPS and Science Act and pandemic assistance, and has the conviction that there is much more to be done. ...

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Krauthammer says there is reason for optimism that the super committee of the August 2 Debt Ceiling and Deficit bill can achieve major results. The reason he says is that much of the work in key areas has already been worked out by the Simpson-Bowles Commission. This has also received extensive public scrutiny and discussion. Its now upto the committe to make some choices for tax reform. For the sake of efficiency and fairness this needs to be done. Efficiency is gained by closing the loopholes and the tax exemptions for mortgage interest deductions, health-care exclusion, and subsidies such as the one for ethanol. And in its place moving to lower tax rates, the 23% envisaged by Simpson-Bowles, or the 28% from the Reagan days, down from the 35% today. Fairness is gained by removing tax breaks for special interest groups that do much of the lobbying. The mortgage interest deduction can be phased out starting at $500,000 in the inital phase or using the plan for tax expenditures proposed by Martin Feldstein. Feldstein's proposal outlined in the New York Times on May 4, 2011, (see group for Feldstein) was to limit the reduction in taxes from deductions and exclusions to 2% of the person's AGI or adjusted gross income. The other part of the Committee's focus would be the structural changes to Social Security and Medicare- raising the Social Security and Medicare ages and changing the inflation formula, and means testing Social Security. Obama has already considered the raising of the age for Social Security and changing the cost of living formula....

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Brooks points out that the best way to arrive at workable solutions is to take the best ideas from all sides of the political spectrum. The Republicans and the Democrats are too ideologically and politically driven and lack the imagination to come up with good solutions.

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How to deal with Bush era tax cuts is a big issue dividing Democrats and Republicans in the U.S. If no deal is reached by Jan 1. taxes on the average middle income family would increase by $2000 in 2013. Median inflation adjusted income declined 8.9% to $50,054 in 2011 from $54,999 in 1999, and economic mobility has fallen. The Democrat's position is for Bush tax cuts to apply to incomes below $250,000. Peter Orszag of the Congressional Budget Office and Jared Bernstein point out that while this makes the tax code move in a progressive direction it also creates handicaps in providing a sufficient revenue base to support middle class spending programs down the road. According to the Tax Polcy Center, if Congress is unable to reach agreement and all tax increases go into effect Jan 1, taxpayers in the bottom 20% of income distribution would see a $412 increase in taxes compared to an increase of $633,000 for the top 0.1%. New York Mayor Bloomberg has supported eliminating the Bush tax cuts for all groups, saying there is no free lunch. Alan Krueger, head of the White House Council of Economic Advisors, says the trends caused by globalization and skill-biased technological change which have increased inequality are likely to continue or accelerate. ...

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David Super, a professor at Georgetown University Law School, says letting the fiscal cliff cuts in spending go into effect is fairer to the poor and middle class than the $1.2 trillion in spending cuts proposed by president Obama and the Democrats. He says the pressure of public opinion would lead to some minideals for the Bush tax cuts to go to lower incomes and for restoring some funds to defense after the fiscal cliff agreement goes into effect, leading to a fairer outcome.

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Monthly reports are issued on bank lending by the Treasury. The report for February shows business lending is down by 24% in its dollar value from the previous month, and a similiar decline in student, auto and credit card lending. The only increase is in mortgage lending as government efforts to hold down interest rates heave led to a refinancing boom. The two largest lenders Wells Fargo and Bank of America reported a 35% jump in mortgage lending in February over January. Businesses are charged more for loans by Chase, which it says is to reflect increased risks, and Chase has sharply reduced its business lending. This is bad news for the economy, because it means businesses will continue to pull back, and some businesses will layoff employees and others may close for lack of financing. The other link to the report in the WPost about the consumers who have jobs, but are acting flat broke suggests consumption will continue to decline, which puts stresses on businesses as sales revenues for all sorts of products decline across the spectrum of the economy. With less acess to costlier financing, and declining sales, the picture of continued large job losses is being etched, and will continue to be etched as these are becoming things that will not change for a long time. Banks are insolvent or close to being insolvent, so lending is only like to change if the government takesover the banks and puses through lending at attractive rates. But it has to do this quickly, before confidence drops to a level where the demand for loans just isn't there. China is able to push lending through the banks because government controls the banks, this cannot happen in the US unless the government actually steps in to take over the insolvent banks and push through a large lending program. In this sense the Obama program while admirable and helpful to stabilize things a bit, is only part effective, and can never really restore confidence or a serious measure of economic stability because of the three pillars of progress in this situation, it can impact only two directly- foreclosure prevention, and business plus consumer lending. The third consumption is something it can only indirectly control through foreclosure prevention and lending, but which is headed down as Americans convert to a frugal lifestyle. And in these two areas of foreclosure prevention and business lending the government is failing. The fourth pillar of progress in the recovery is employment, and this is also an area the government can only indirectly control through stimulus spending on infrastructure, education and energy, but is largely influenced by foreclosure prevention- which keeps home prices from falling rapidly and overshooting and reduces household wealth- and business/consumer lending. These are ER (f) FPL (CE). Economic Recovery as a function of Foreclosure Prevention and Lending, and Consumption and Employment, where indirect control is shown by ( ). With not much in place for FPL- the only two variables government can directly control if it takes strong and immediate action before its influence on these two variables begins to diminish over time- Obama's inexperience and learning curve and failure to take bold action to get serious results on FPL, may result in admirable demeanor and rhetoric but medicore results and a struggling economy for years to come. ...

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The Fiscal Survey of States, a report put out by the National Governor's Association, says that Medicaid will become an increasing burden on state budgets as help from the federal government declines. The report points out that state general fund revenue remains $21 billion below 2008 levels, just as the states prepare for less federal help.

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Robert Morgenthau, District Attorney for Manhattan, 1975-2009, says there is more money on deposit in the Cayman Islands, than in all the banks of New York put together, with 19,000 companies listed there. Cayman is one of several tax havens. Apple use Luxembourg for iTunes. Other tax havens are the British Virgin Islands, Gibraltar, Antigua, Bermuda, the Bahamas. He cites the Senate's Permanent Sub-Committee on Investigations in 2008, which gives the estimate of $5 trillion to $7 trillion sheltered in offshore places on this list, by Americans, Chinese, Europeans and others. Morgenthau says these tax havens help American and European companies not only to avoid taxes, but also structure complex international transactions. He estimates these transactions cost the U.S. Treasury about $40 billion from outright tax fraud each year.

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The coronavirus pandemic and the disaster in nursing homes, the chaotic conditions in the first wave, the lack of staff and poor attention to residents during the pandemic, has exposed the major weakness of nursing home care in western countries. Much of this sector is in the hands of private operators seeking a profit.  The staff is paid low wages and lacks the experience and empathy needed for care of older people. During a virus all these factors turn deadly. With some staff sick the other staff is overburdened. If the sick turn up for work they are likely to risk the safety of other staff and the residents. With the incubation period lack of testing there is no way to know. When deaths occur and the nursing homes are sealed from the outside world the deaths happen with no goodbyes as happened in U.S., Britain and Sweden. This has exposed the scandalous and shocking way in which the elderly are treated in today's environment where ridiculous amounts of money are being spent on other things and the the most basic "one's parents" are neglected and allowed to die in horrific manner in a pandemic. The new trend for home care for the elderly is a welcome trend and long overdue as one of the worst aspects of the system in the west is the treatment of elderly parents in nursing homes run for profit. The new technology tools available for monitoring a elderly person at home, and the help of stores such as Best Buy which are serving elderly at home, is making this more and more a choice for the elderly. Even older patients and ones needing significant care can recover and spend time at home in a better environment, a less costly one, as hospital managers and families have learned in 2020. Some hospitals in the U.S. say they never want to go back. That the drive to get every patient home who can be home is the right one for patients and families and for the government paying for the care so that dollars are well spent in quality of care. Home health care companies are working on providing new services for sicker patients recovering at home. Technology helps do better monitoring. Medicare now pays for digital doctor visits and intense hospital type care at home after coronavirus showed this as vitally needed.  Both the Biden and Trump administrations are firmly focused on this issue. Seema Verma as head of Medicare is clear about the need for a national conversation on how we take care of the elderly, of our parents. And Mr. Biden wants to spend $450 billon to make certain that people who need long term care can get the support they need in the home and the community. This report looks at the home health care companies and how they are improving their services. This and telemedicine are two of the major constructive changes coming out of the pandemic, clearing out some of the worst aspects of the old system of living the older years in the western world.  Nothing speaks more about humanity and a human world than the story here of Savanna Hollar, 90 years old and almost blind. She broke her shoulder in August, Her sons decided not to send her to a the rehab facility she went to after a broken hip 3 years earlier. The sons brought her home to recover in the farmhouse near Yadkinville, N.C., where she has lived since 1951. One of her sons himself 63 years says that at a nursing home she would be lonely, scared and afraid to move. The sons hired two people to help her during the day and a rotating system was used for having people help her. At home Mrs. Hollar could enjoy her gray cat, Buddy, her favorite recliner and tomato sandwiches made with produce from her garden. Really, if we can't do this much what good is the U.S.A.? or Britain? or Sweden? or India? ...

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The Senate FInance Committee's $829 billion bill, would cut by $113 billion money for America's Health Insurance Plans over ten years, specifically Medicare Advantage, reducing insurer profits. The AHIP is responding with aad campaign to seniors to fight this setting up aconfrontation with the Obama adminsitration.

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The Romney story says this editorial is one of a turnaround- of a kind patiently nurtured from his days turning around businesses as a management consultant. This one was different and probably required a lot of soul searching and courage to take up new positions. As a technocrat, says the Journal, Romney would have been more comfortable with a room full of IQ's going over spreadsheets of numbers. He tried to do this by not taking up specific positions till the need to convince voters, first in the GOP base and then centrists and independents after the convention, forced Romney to make the reassessment and turnaround he needed to make. In November 2011 he accepted the Ryan position that Medicare needed changes, and in Feb 2012 he took up the case for lower tax rates and cutting deductions. In October 2012 came the first debate, with it Romney abandoned his reluctance to put forward a plan for the economic recovery and put forward his five point plan. That was the turning point in the campaign but all the other steps including the selection of Ryan, a Congressman from a working class district in Wisconsin, agianst the advice of advisors, were leading up to this turnaround. This was likely the most difficult of turnarounds, even searing in its soul searching as Romney scribbled "Dad" on paper at the lectern before the first debate- turning back to beginnings he had doubted for so long....

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Ron Wyden, Democratic Senator from Oregon, on maintaining competitive choice for 200 million Americans who have to buy insurance outside the Exchange proposed in many of the bills being put forward in the U.S. Congress. This lack of choice between seriously competitive plans will leave the situation in the same way that it is today, with little hope for controlling runaway costs and doom health care reform. The key to controlling costs says Wyden is introducing choice and competition. Wyden will introduce this plan as an amendment called Free Choice to legislation being debated in Congress.

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Peter Coy of Bloomberg Business Week points out that the debt ceiling and proposed deficit reductions in the range of $4 trillion really obscure the real size of the problem which is much larger. The real problems hit when the U.S. faces a larger graying population by 2020 with sharply higher per capita health care spending; and at the same time workers from this generation retire and become beneficiaries of Social Security and Medicare with fewer younger workers to support the system with tax revenues. Another problem is that older Americans are likely as a voting bloc to vote themselves benefits that will cost the younger generation, benefits that the younger generation will not be able to enjoy. Even the Paul Ryan plan with its cuts to Medicare insulated todays seniors from the sharp cuts, as it becomes political necessity for both Republicans and Democrats to shy away from touching the current beneficiaries.

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Reps. Eric Cantor (Va.), Kevin McCarthy (Calif.) and Paul Ryan (Wis.) have jointly written a book "Young Guns," that completely distances the new leadership in the Republican party from the leaders of a prior generation. The book says the older Republican leadership "betrayed its principles," by not controlling spending. See the the link to David Stockman who has criticized previous Republican administrations for their attitude to spending, including President Reagan. A recent NBC/WSJ poll shows only 24% of those polled seeing the Republican party positively. The idea is to differentiate the younger leaders as new voices in the party, different from the party's previous role.

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Britain's Tax Service reports the number of taxpayers reporting incomes of 1 million pounds a year declined by over 60% in fiscal 2010-2011 from the prior year. In 2010 the Labor government of Gordon Brown introduced a 50% income tax rate for this income group, up from 40%. The number of million dollar incomes filed declined to 6000 from 16000 in 2009-2010, and revenues declined from 13.4 billion pounds or 9% of total taxes from taxpayers to 6.5 billion pounds or 4.4% or about half. The Labor government had hoped for additional 2.5 billion pounds in revenue, showig unintended consequences and surprises in economic policies.