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The tough job President Obama faces as he faces opposition from politicians who have interests to protect, and healthcare businesses with interests to protect. The President has to come up with a plan that is deficit neutral, because financial markets could see a healthcare bill that further widens the deficit as a signal for higher interest rates that would deepen the recession. At the same time each of the three sources of revenue puts him at loggerheads with political leaders in Congress or groups with interests to protect. Limiting income tax deductions for high earners could raise $267 billion in 10 years. It would require taxpayers in the top tax brackets deduct their mortgage interest, state and local taxes, and charitable donations, at the 28% tax rate instead of the 33% and 35% tax rates. The opposition is with democratic leaders that it would hurt charities, universities that depend on tax deductible donations, and taxpayers in high tax cities like New York city that are the home base of Democratic leaders. Yet only 1.4% of households would be affected says the nonpartisan Tax Policy Center. The Center on Philanthropy at Indiana University, says charitable giving would decrease by 2%. The other opposition on this comes from the preference of Senators Baucus and Grassley, who head the Senate Finance Committee, for tax increases or cost savings to come from the health sector. Specifically they want to see the value of workers' employer provided health benefits subject to income taxes. It is a situation in which every sensible person admits the need for healthcare reform and would see the current pace of healthcare costs as unsustainable and dangerous; and after that will just go back to his group and try to preserve as much of the status quo as possible, so as not to disturb by much the benefits or compensation they have secured from the system over the years. Then there are political leaders in Congress with their own preferences, and Congressmen who are the subject of heavy lobbying by these interests. The administration and the Presidents job is to navigate this stream with a workable deficit neutral plan, without any requirement for any group to make sacrifices, and in some situations even small sacrifices for the public interest. Would charitable institutions be hurt that much, what if charitable institutions were exempted, why would other interests the try to obtain the same exemption. Its like the unions trying to keep the old unsustainable goldplated healthcare and other benefits at GM even as the ship was going down. Taxing employer provided employee health benefits as income would raise $2.5 trillion over a decade. The opposition here is from unions which are a force in the Democratic party and which count tax free health benefits as a legacy of the labor movement. Employer provided health insurance covers 160 million American employed and their dependents under the age of 65, so it has a wide impact. Yet most economists favor ending the tax break. They say it mainly goes to upper income taxpayers, and discourages cost consciousness among consumers of health care, thus encouraging excessive spending and surging health care costs. Senior Obama advisors, Peter Orszag, the budget director, and economist Jason Furman favor this approach. So do Republicans in Congress. Senators Baucus and Grassley are not asking for the complete removal of the tax break, what they want to see is capping the value of benefits that go untaxed. If the tax-free limit is $13,000, a policy worth $15,000 would pay income taxes on $2000. A third spource is to spend less on Medicare. About two thirds of the $948 billion in savings Mr Obama has proposed over 10 years comes from a number of reductions in Medicare spending. $177 billion comes from insurance companies bidding for government reimbursements for offering private plans to seniors. $106 billion comes from cutting the subsidies to hospitals serving the uninsured as universal coverage should remove this need. And $110 billion in reduced payments to hospitals and doctors because of productivity gains. A range of industries insurance companies, hospitals, doctors drugmakers, nursing homes, home health care companies and medical device makers, all stand to lose from reduced payments from Medicare and Medicaid. And these groups with interests to protect are another factor in this process of working out a healthcare plan. ...

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Glaxo's Dr Garnier talks with Jeane Whalen of the WSJ about his work, a lot about his committment to running a company not just for rich countries, that access is a very important word for him and his efforts to make drugs affordable or even free or close to free depending on the country's standard of living, his 24-7 day handling the Avandia issues, and the innovative drug pipeline he has put together over the years.

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A second inaugural address in which Obama outlines his priorities and liberal vision of America.

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Areas for growth for the Indian drug Industry include the large growing domestic market, the outsourcing by US drug manufacturers, and sales in other developing countries of Asia, Middle East, Latin America and Africa. Analyst estimates are that India will spend $30 billion a year on drugs to improve care for its people in the next 10 years up from $8 billion today. And the distribution network is being developed by drug companies insdie India to reach more people. Also companies like Pfizer plan to double outsourcing of manufacturing drugs from 10% today to 20%.

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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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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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How diagnostic tests in portable toolskits, that patients can use themselves, are being developed at low cost in developing countries like China. This creates the kind of care appropriate for poor countries, where patients need something they can afford, and something that does not require repeat visits to doctors offices or clinics. Ustar Biotechnologies is a Chinese startup, that says it has the technology, costs that the founder says "no one can compete with," and affordable prices for poor countries. The sales of such diagnostic test portable devices or kits is expected to soar in coming years. Quimin You, the inventor and founder of Ustar, graduated in North America and worked with multinationals. His proposals for cheap diagnostic technologies were turned down by multinationals, who in their narrow focus saw these thechnologies undermining their existing products. Now Qimin is back in China with a startup that will do this.

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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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Th cost of cancer drugs Avastin and Erbitux and the need for putting life savings at risk for a few months of treatment create tension among families, doctors and treatment providers. A course of Avastin could run $56,000 and take 90 days for reimbursement by meicare or pricate insurance, and a 20% co-pay comes to $11,200.

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Problems with China's health care system stem form years of underspending. About 1% of GDP went to healthcare in 2006,according to the WHO, ranking China at No. 156 of 196 nations. This underinvestment has caused great hardship to the rural poor who have postponed or been denied access to healthcare because of exorbitant expenses. It shows up in the number of trained medical workers- only 17% of China's medical workers are university graduates. In village and township clinics the number falls to 2%. The government has dedicated $121 billion for health care through 2011. But this may not be enough. Aobut 300 million in the rural areas have no coverage at all. The government's plan is to get farmers insured through county level rural- cooperative insurance plans. These programs begun in 2003, offer only scanty coverage. Outpatient services and medications are not covered and coverage varies from county to county for hospitalization bills. The goal of th health ministry is to get the coverage for hospitalization bills up to 50%....

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New ways to price drugs based on how well they work for patients.

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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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Rick Perry faces criticism from Republican candidates Romney, Bachmann, Huntsman and Paul at the Republican presidential candidate debate in Tampa on September 12, 2011. Perry defended his remarks on Social Security by telling viewers- "slam dunk guaranteed that program is going to be in place." Romney suggested Perry had been served four aces for his jobs record in Texas. And Santorum accused Perry of providing education assistance to illegal immigrants to attract the Latino vote. Perry defended his remarks on Fed chairman Bernanke printing money amounting to treasonous behaviour.

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A shift to a limited agenda based on increasing the minimum wage, immigration reform and use of executive orders to get things done.

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Lipton, Austin and LaFraniere of the NYT tell the story of how the serious differences between the prime contractor for the federal healthcare website, CGI Federal, and the Obama administration officials handling the website, evolved into conflicts that could not be resolved. This led to the flawed website being rolled out on schedule ignoring serious problems with the website. The detailed report comes after interviews with Obama administration officials and specialists who worked on the project and looking into government and contractor documents. A month ago in October 2013 the healthcare website for the Obama healthcare law was up only 42% of the time with 10 hour failures happening frequently. Basic steps for the functioning of website backup systems in case there is a failure, testing to ensure negligible or no outages, were not secured. The government officials responsible for the rollout did not have the capabilities to handle such a project. Henry Chao, who worked in the Medicare agency for 19 years was left to oversee day to day questions for the website HealthCare.gov, but lacked a formal background in software engineering and no authority to make the decisions needed. The $630 million project was setup inside the Medicare Agency, instead of a separate agency specially setup for this project and staffed with the appropriate skills as originally proposed. Five different lower level government officials made decisions without the authority needed and no one person with the necessary skills was given overall responsibility and decisionmaking. A series of missteps were allowed to take place- settting many added requirements that made it difficult for contractors to focus on basic steps and get them right, use of the MarkLogic database system instead of systems from IBM or Oracle against the advice of contractors, multiple contractors without a way to control the overall project, shifting requirements from the government and bureaucratic delays for resolving basic issues such as use of social security numbers, all worked to create delays. With the delays came a deterioration of relations between Obama administration officials and the contractors. The government officials response was to stick to the deadline of Oct. 1 rollout, with Michelle Snyder, chief operating officer of Medicare agency telling people she would fire the contractor if possible. In the end no one took responsibility for a safe reliable rollout, even though the system failed a test of 500 users in late September and was down half the time in mid-October. President Obama or his advisors were either not kept fully informed, or did not grasp the significance of the collapse in relations between contractors and the government and a project out of control. His aloof distanced approach was not an asset in such matters- saying about the rollout and use of the website: "this is real simple" like using the Kayak website for travel bookings- and he saw no need to take action leading to the major failure for the administration that followed....

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UnitedHealthcare says it will keep parts of the healthcare law relating to preventive healthcare services without co-payments, allowing parents to keep children on insurance till age of 26, even if the Supreme Court rules against the healthcare law. Most insurers see these parts of the law that are popular quite favorably.