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Questions being addressed to get health care to the uninsured and to all Americans at an affordable level.

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The public option as anecessary step for effective cost control in healthcare in the USA. The potential for higher healthcare costs in the future gutting the whole effort to provide universal health care if there isn't the money to pay for it. Which means that if the public option brings costs down its anessential part of any healthcare program that is sustainable years from now. Krugman calls for audacity from the President.

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Senate Finance Committee chairman says Senate Democrats have found ways to reduce the cost of the health care plan from $1.6 trillion to $1 trillion. A tax on some employer provided health benefits, cuts in Medicare and Medicaid spending, employers helping to pay the cost of health insurance for low-income workers, and limiting the eligibility for subsidies to households with incomes at 3 times the poverty level or $66,150, instead of 4 times the poverty level. Also a reduction in the plan to give tax credits to small businesses to help them buy insurance. And expansion of Medicad would be delayed to 2013.

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The American Medical Association came out against the public option in President Obama's health care reform plan. The outpouring of comments on this article show that public opinion today seriously questions the actions of the AMA, and think that this is not in the best interests of the nation. Its the kind of outpouring of criticism that GM's old management received from readers fed up with the management of the Detroit automakers, before the GM bankruptcy. Out of the 26 most read or recommended comments on this article shown on the link to the article in the NYT, 25 were strongly critical of the AMA's position on health care, none were in favor, and one was critical of the insurance companies. The 25 that were strongly critical had a total of reader recommends of 6539 readers when they were totalled up for all 25 comments. Some of these comments were strongly critical and explained at length why. Some were from doctors who disassociated themselves from the AMA. One suggested that the American College of Physicians also represented doctors, and the AMA represented only one group of mostly older doctors who are against any change. The financial crisis and the election of a new President, the changes in the country since the last failed reform effort in 1993, the new mood of the country as it changes to its more frugal past, a new generation of doctors and a new generation of young people coming to the fore, all may mean that things are no longer the same, and actually very different. Are the people running the AMA, like the people who were running GM a short time ago, not able to see how they are perceived by the public? ...

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To overcome resistance on Capitol Hill Obama takes his proposals for health care to the states and back to the grassroots support that got him elected. He will hold atown hall meeting in Virginia on health care. Obama advisor Axelrod says the main thing is to show what widespread support Obama's proposals have across the country. As ameans to this Obama's main political group Organizing for America will swing into action in the weeks ahead.Obama is talking to governors, Democrat Christine Gregoire of Washington, and Republican Michael ROunds of SOuth Dakota,

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The Institute of Medicine releases areport of the 100 health topics that should get high priority, as the Obama adinistration proceeds with a plan to $1.1 billion to compare the effectivenesss of treatments. Some of these areas for research are prostate cancer treatments, a surgical procedure called ablation, and others.

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The NYT editorial says budget reconciliation should kick in if by a certain date in the fall bipartisan agreement is not reached. With budget reconciliation, the term for a expedited processs, health care legislation can pass by a simple majority vote. NYT says bipartisan agreement is a good thing, but more important is effective health care reform. And there is little evidence of Republican cooperation so far on any issue.

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WSJ's CEO council advocates a goal of 10% electric cars by 2020 and upto 50% of the fleet by 2030. Other top priorities of the CEO's from Google, Intel, Time-Warner, Fedex and other companies at a recent 1 day conference were obesity, a stimulus program in excess of $300 billion, and restarting the Doha round of talks for global trade.

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With 10.3 million workers unemployed according to the Bureau of Labor Statistics, and this includes 2.8 million added this year so far in 2008. Most of the people who lost their jobs also lost their health benefits. This increases the urgency for the Obama administration to come up with action in the health care area as the ranks of the uninsured will grow in 2009.

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CEO Ryan at CVS/Caremark. An unassuming man with a sharp focus on things, joined CVS right out of pharmacy school at University of Rhode Island. At 29, CVS owner Stan Goldstein gave him the chance to run pharmacy operations for CVS, then a regional drugstore chain in the eastern USA. Over the years CVS has made a number of successful acquisitions, the latest being the acquisition of Longs Drug store chain on the west coast, and it is now one of the largest chains in the USA. It has nearly 7000 stores and more than 50 million users of its CVS loyalty card in the US. As the pharmaceutical business evolved pharmacy benefit management (PBM's) companies like Caremark, Medco, and Express Scripts, came into being to manage burgeoning prescription costs. PBM's work with companies to save money, by filling recurring prescriptionsin 90 day quantities through the mail at reduced per pill cost. Now drug store chains instead of competing with PBM's are either creating or acquiring these larger PBM's. THe result is that a company like CVS which acquired PBM Caremark in 2007 for $27 billion, now has extensive computerized databases with patients information and drug usage histories. Ryan's clear focus is on these IT records as a distinct advantage, if he can use it to help the Obama administration's efforts to control health costs of chronic diseases like diabetes and arthritis, and back or neck pain, high blood pressure, and others, that end up clogging the hospital system and raising health care costs. By using these IT records to flag when a patient is not compliant or taking his medications and call the patient, Ryan can increase drug sales, get more visits into drugstores if the drugs can also be picked up at CVS stores, and increase sales through ancillary purchases during visits. This is now his strategy. It also includes setting up more clinics at stores and at corporate locations that divert the patient flow for small care like sore throats, flu and the like. As this is the way health care costs can be controlled, Ryan sees himself as helping achieve national goals while keeping CVS in the sales and profit picture for the US, even as health care as we know it goes through a complete transformation that removes the waste and unnecessary cost, and improves effectiveness and health. He sees CVS/Caremark right where it wants to be with its large patient drug database from about 1 billion prescriptions it fills each year, and as the largest single buyer and dispenser of prescription drugs in the country. ...

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Amy Goldstein spends time in Janesville, Wisconsin, in U.S. vice presidential candidate Paul Ryan's congressional district, and talks to local people to give a glimpse of life in Janesville after the closing of the GM plant and the 2008 financial crisis. She looks at the effects of long-term unemployment and cuts in services in communities such as Janesville as a public policy scholar at the Woodrow Wilson International Center for Scholars, while on leave from the national staff of the Washington Post. Ryan was first elected to the U.S. Congress in 1998, about a decade before the closing of the GM plant, and has been reelected to Congress each time for 7 consecutive terms. Goldstein says Janesville is typical of the communities across America that have suffered job losses- the loss of more jobs in manufacturing than any other sector, a greater impact of job loss for men than women, and a large impact on people who had less education but well paid jobs. As shown by the recent settlement for a Caterpillar plant in Joliet, Illinois, and across the U.S. manufacturing landscape, older workers who enjoyed higher wages are retiring with newer workers coming in at a lower wage, which is improving U.S. manufacturing competitiveness but also increasing the importance of education for higher paying jobs....

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Just as the drug industry is more getting more dependent on the government with the medicare drug benefit raising the retail drug purchases paid by government to 34% in 2006 from 28% in 2005, the industry is facing more governmental scrutiny, from the FDA, from Congress from the public, and during this election campaign. Rep .Rosa DeLauro, who heads the House appropriations subcommittee that has oversight over FDA funding compares the drug industry to the tobacco industry saying that it requires the same amount of scrutiny. At the same time the drug industry is aware of the changes in the public mood and the recent controversies over drug studies, such as the one on Vytorin and other controversy. It is initiating some voluntary changes, registering clinical trial results, submitting commercials to the FDA before they air, and under pressure from medical journals registering trials before they are performed. A new law will requires and its not clear whether the drug industry is dragging its feet and then making changes when there is increasing public pressure. This is the feeling of the medical journals like the Journal of the Medical Association and the New England Journal of Medicine. JAMA's editors will be keeping up this pressure as they have more articles showing how the drug industry manipulates data and the need for public skepticism of information that comes out of the drug industry. The New England Journal editors expressed the need to publish information that helps doctors get all the available information, and not just the information from the drug industry that makes the drug look better than it really is, such as the information and analysis it provided on antidepressant medications. The chairman of the energy and commerce investigations subcommittee Rep. Stupak, finds the advertising for drugs contains information that cannot be backed up and not true ethically, medically, or legally. As this reflects the public mood look for more investigations in Congress and investigative research by the journals. On the issue of importation of drugs from Canada there is bipartisan support as both Senator McCain and Senator Clinton support importation. Clinton supports legislation that allows the FDA to approve new generic versions of biotech drugs which would lower prices of biotech drugs. And with the US consumer budget facing strains in a recession there will be increasing pressure and demands for relief in the area of drug prices, especially for the elderly and uninsured and from corporate payors. ...

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President Obama has 63% job approval rating in a New York Times/CBS News poll. His backing is among Democrats and independents alike which is very useful for Obama.But the poll shows more American having faith in the President than in the handling of specific issues. He gets good approval on foreign policy initiatives at 59%, but in the handling of the Auto bankruptcy, or of health care his ratings are below his personal ratings as President. A majority of those polled were concerned about the rising budget deficits. BUt his ratings among Republicans has fallen from 44% in February to 23%. Republicans were viewed favorably by only 285 of those polled, the lowest ever.

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Krauthammer cites Congressional Budget Office numbers that show the Obama U.S. health care law continues the spiralling costs of health care with new government mandates at a time of severe budget cuts in education and other areas- for 2013-2022 the costs come to $1.76 trillion. The initial Obama administration figures of 10 year costs of $938 billion announced in 2010 reflected the fact that the new U.S. health care law would take 4 years to fully go into effect. Costs after 2021 are shown to be $250 billion each year in the CBO figures. The law is now before the Supreme Court in 2012, which has to decide on the basis of the limits of the Commerce Clause.

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A short biography of Wisconsin Congressman and Romney's vice presidential pick, Paul Ryan.

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The Economist cites the Dartmouth Atlas Project which shows differences in cost across the country for health outcomes and spending involving Medicare. It cost $5000 per person in Salem, Oregon in 2006, $8000 in San Francisco, and more than $16,000 in Miami, with outcomes for health tending to be better in places where the costs were lower. This is one of the statistics that Peter Orszag of the Congressional Budget Office uses to come up with his estimate of 30% waste in health care spending in the United States. Prof. Skinner at Dartmouth and Prof. Garber at Stanford point out that of most health systems around the world the American system is "uniquely inefficient" and wasteful. The Economist cites information that the American system is twice as costly per person for healthcare than the Swedish system, and that it costs twice as much in Minnesota as in Miami. A poll done for the Economist shows 52% of the people in the UA are dissatified with the quality of care, 40% think the system needs fundamental change, and 29% think that it should be fundamentally rebuilt. The lack of uniform coverage is also causing turmoil in the system. About 49 million are uninsured, and a quarter or more are able to buy insurance and do not buy it because it is so costly, has exclusions and coverage is inadequate. But these people also end up in the emergency rooms along with the indigent costing the whole system tens of billion of dollars for costly late interventions that could have been avoided with preventive care early on. With the economic crisis and rise in joblessness, the dire condition of state and local budgets, the situation has probably drastically worsened, and the system near breakdown. ...

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Ezra Klein says about the contrasting choices offered by Romney-Ryan vs Obama-Biden, that everyone wanted to see a clear choice between different approaches to the issues, and now they have got one. Its almost a repeat of Reagan-Bush vs. Carter-Mondale during a period of high unemployment with Democrats risking underestimating the importance of the careful choice made by Romney today.

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Rep. Paul Ryan got his start in politics in 1983 when he was hired to work for a think tank Empower America. This think tank was formed by Weber, Kirkpatrick, Bennett and Kemp, to preserve Reagan era ideas of focussing on economic growth generated by private investment. This was followed by working as an aide to Senator Brownback of Kansas and Rep. Jack Kemp till his election to Congress in 1996. Kemp was the big idea guy and it was Paul Ryan who delved into the budget details at the time to support Kemp's ideas. Kemp was Republican vice presidential candidate, the same position that Ryan is in today. Ryan represented the area around Janesville, Wisconsin, in the U.S. Congress. He graduated from the University of Miami, Ohio.

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Clarence Cammers, 64, one of Paul Ryan's constituents back home in Wisconsin, has a question for Ryan at one of his townhall meetings. Clarence is worried about what would happen to his son Tim, 32, if Medicare cuts went through and his son had to use vouchers for getting health insurance. Ryan's district includes Racine withe high unemployment, and Janesville which was devastated by the closing of the General Motors plant in 2010. Most of the people there are conservative, believe in fiscal responsibility and a balanced budget, but they are also older, working class people. Some of them like Clarence are dependent on their Social Security check to get by from month to month and are not sure they can cope with the kinds of cuts Ryan is proposing. In this story Clarence and Tim discuss the meeting and come to the conclusion that Tim will lose either way- with taxes going up or Tim not getting the retirement that he should be getting. Clarence a life long saver decides he will cut back on his expenses and save $588 from his $1912 monthly social security check for Tim. Tim has severe attention deficit disorder and works for $10 an hour in food prep at a resort....