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The basic outlines of new health care legislation takes shape as Senators Dodd and Kenedy come up with a plan that scales down subsidies to low-income people to buy insurance. Attached to their revised outline is a budget office analysis thatprojects the plan costing $611 billion over 10 years and with expected changes from the Senate Finance Committee would cover 97 percent of all Americans. And earlier plan received much criticism because the Congressional Budget Office estimated its cost at $1 trillion over 10 years and left 37 million Americans uninsured. In addition there is the revised Medicaid expansions for aid to the poor that would add a couple of humndred billion dollars to the total tab. The administration's goal is to keep the cost down to $1 trillion over 10 years. The legislation as it stands includes the public option which is designed to control insurance costs. Mr. Obama said this week that "the public option would keep insurance companies honest." Employer mandated insurance is part of the Kennedy-Dodd legislation proposal. Employers with 25 or more workerswould have to provide coverage or pay the government an annual fee of $750 for each full-time worker and $375 for each part-time worker. The government pays the startup costs for the public insurance option as a loan to be repaid, and premiums would make the option self-sufficient....

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President Obama in his speech at Georgetown, April 13, 2009, describes the thinking behind the decisions made in the first 12 weeks of his administration- why the actions are not aggressive and overreaching as some critics say, and why they are not timid as other critics have said. This was not a typical downturn of the business cycle, but a perfect storm arising from irresponsibility and poor decisionmaking in Washington, Wall Street and Main Street- in effect several crises colliding for something like an explosion, if not dealt with at once, and with strong action. He says "the key to dealing with our deficit and debt is to get a handle on out-of-control health care costs, not to stand idly by as the economy goes into free fall." The recognition that the crisis itself brings with it new possibilities, the opportunity for coming to grips with and forging a good solution to health care, energy and education issues that were neglected while Wall Street directed investments to areas other than investment in building for the future. To the critics like Krugman, Rosenfeld and others who say that the takeover of insolvent banks should be done quickly before the situation worsens, he says it is not because of any ideological or political judgement he has made about government involvement in banks, but because it is more likely to undermine than create confidence at this point. He goes on step by step, through the process of decisionmaking, first to step in and boost spending vigorously, second to get lending flowing again to businesses and families, strengthening the non-bank credit market for consumer purchases and loans, the housing plan, the auto plan, and the work at the G-20. Then President Obama goes on to project his vision and the road to getting there. The five pillars he sees for the future are: redirecting Wall Street and banking to constructive investments for the future, investments in education, investments in renewable energy and technology to create new industries and new jobs, investments in health care to cut costs for businesses and families, and new savings in the federal budget to bring down the deficit. Obama says he will look for savings line by line in every corner of the budget, and has already identified two trillion dollars in deficit reductions over the next decade. And the goal is to reduce discretionary spending for domestic programs as share of the economy by more than 10% over the next decade. Procurement reform will greatly reduce no-bid contracts and save $40 billion. Secretary Gates is attacking th problem of hundreds of billions of dollars in waste and cost overruns that have bloated the defense budget, without adding to the nation's safety. And education programs that don't work will be removed, and waste, fraud and abuse in the Medicare program will be controlled. Finally, Mr Obama points to the nation's political system as one more reason we are in this perfect storm- "a fundamental weakness in our political system." He cites the putting off hard decisions for another day, scoring political points instead of rolling up up sleeves to solve real problems, an impatience that is only worsened by the 24 hour news cycle, and a short attention span that focusses on the immediate results and on poll numbers. And there is too much responding to the "tempest of the moment until the furor has died away and the media coverage has moved on, instead of confronting the major challenges that will shape our future in a sustained and focussed way." After these 12 weeks President Obama says, for the first time there are glimmers of hope, and way off in the distance can be seen a vision of America's future that is far different than its troubled past. And citing the parable in the Sermon on the Mount about that "house built on a rock", he sees America's house built on a rock, a house for which we use this moment to lay a new foundation, come together and begin the hard work of rebuilding, persisting and persevering in the face of disappointments and setbacks that surely lie ahead. Then he has no doubt "that this house will stand and the dreams of our founders will live on in our time." Its a remarkable speech in its directness, its simplicity in approaching the subject, and its borrowing from the Bible for that story of that house built on a rock, and its Lincolnesque reference to the house that will stand. And more than a speech, it describes a vision, and the set of actions and steps taken and to be taken to get there. ...

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Paul Ryan, chairman of the House Budget Committee, explains his U.S. budget proposal to bring down the deficit. Ryan's Republican budget proposal is a bold effort to make a break from a status quo which is leading to higher levels of U.S. debt as a percentage of GDP. It envisions changes to Medicare, Medicaid, and the tax code. It is built on the idea that sustainable finances will lead to a better economic future for America, compared to small changes to the staus quo envisioned in Democratic proposals and the 2012 budge proposal of the Obama administration. It is also bold in its effort to tackle Medicare with a "premium-support" system, and Medicaid by turning it into a block grant system. It also incorporates the Bowles -Simpson President's Deficit Commission's ideas for simplifying the tax code.

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This New York Times editorial describes the impact on lower income Americans of spending cuts that are part of the Romney-Ryan plan.

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Leonhardt argues that rationing is rational allocation of limited resources, health care budgets are limited resources even in rich countries like the USA, and if you overpay here you cut somewhere else. Now the cuts that are not noticed he says are in take home pay as employers face increased premiums from insurers. Rationing is taking place all the time with poor health outcomes relative to the cost for poor allocation of resources as survival rate for many diseases are not that much better than other countries. Rationing takes place everyday when patients see doctors only for a few minutes as doctors race to see more patients, and when diseases are not caught early on in the process as doctors do not know their patients well enough. And rationing is taking place as patients simply delay or forego treatments based on the extra cost, or as uninsured get no care. There are so many buzzwords like this thrown around, with doctors, hospitals and insurers and other groups trying to preserve the status quo, even as it is becoming rapidly unaffordable fort the US to be spending so much on health care....

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In a new WSJ/NBC New poll, conducted July 24-27, 2009, 42% called the Obama health plan a bad idea, and 36% called it a good idea. In mid June the poll showed Americans evenly divided on this question. It reflects rising anxiety over the costs of the health plan and what it will do to the deficit, and also shows public anxiety about the ways in which Obama and Congress are reaching compromises to pay for it and to control costs. Added to this are the anxieties raised about government involvement in healthcare and medical decisions about care. Noteworthy are two differing pieces of evidence. In the WSJ/NBC News poll, only two in ten people thought the quality of their own care would improve, only 15% of those with private insurance thought that it would improve the quality of their care. And 4 in ten people thought quality of care would get worse, and 45% of those with private insurance thought quality of care would get worse. By focussing on the cost of health care, the administration seems to have ignored or missed the concerns of people about the quality of care if government focussed on cutting costs. These concerns are real as a vast majority of the public, or about 85% of the people, as Martin Feldstein points out in a recent Washington Post column, are insured. The question is what cost would they be willing to pay for the admittedly worthy cause of insuring the uninsured? And even with the unisured, it seems likely with the current Obama reform plan that immigrants and other people may still remain uninsured, at least for some time. Would a huge burden of $1 trillion make this worthwhile, and is there some better way to do this without the prospect of higher taxes further down the road to pay for this. These are points Feldstein makes. The other piece of evidence is that at the same time that there are reservations about what is coming out of Congress today, there is general support for making constructive changes to healthcare. The WSJ poll showed 56% of respondents favoring the basic ideas in the reforms being considered in Congress, with 38% opposing it....

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Dan Maffei won his Congressional seat from an incumbent Republican from Syracuse. Others of the 35 first term Congressmen represent a rural, small town and suburban areas like Maffei. And they are not about to lose their seats after tough congressional campaigns, they say, by voting the wrong way on health care reform. As one from Maryland put it he is not willing to foloow the lead just to follow the lead. These are the Congressmen that Steny Hoyer, Rep. from Maryland, who leads the Democrats in the House, wants to give more time as this is what they wanted. And these Congressmen are making themselves heard and making changes in the health care legislation where they disagreed.

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This Washington Post editorial says vice president Biden's comments that "I guarantee you, flat guarantee you, there will be no changes to Social Security. I flat guarantee you," made to a voter in Southern Virginia, is downright disheartening. It points out that this is not the conclusion of the trustees of the Social Security Fund, which includes the secretaries of Treasury, labor and health and human services of the Obama administration. The April annual report of the trustees says that the disability portion of the trust fund "becomes exhausted in 2016," and the overall fund "becomes exhausted and unable to pay scheduled benefits in full on a timely basis in 2033." Actions suggested by the trustees include: raising the payroll tax, tweaking the inflation calculator, reducing benefits, or some combination of this. It is clear from polls that the U.S. voter does not want either party to touch Social Security, but the reality is something different. The idea of a flat guarantee in the light of facts that all can see is seen by the Post as going too far, trying to win votes at the cost of postponing necessary decisions which will become harder and costlier if not addressed early....

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Krauthammer tells U.S. presidential candidates stop saying that Social Security is a Ponzi scheme, because by its very definition it is a Ponzi scheme. Instead exercize common sense and take the simple steps to update Social Security for today's longer life expectancy, aging population and way fewer workers to support a retired person. In a Ponzi scheme payments by people joining currently are paid to those who joined earlier, with not enough to pay future entrants- which is what is happening to Social Security. In 1940, after Roosevelt signed Social Security into law, there were 160 workers for each retired person. That dropped to 16.5 in 1950, today there are 3 workers. In 1940 the life expectancy was 62, today it is closer to 80. Krauthammer says the writing is on the wall- simply have the courage to make the changes by raising the retirement age, means testing the rich for benefits, and adjust the cost of living measure.

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Walk in clinics at drug stores like CVS and stores like Walmart now have the cooperation of hospitals. Hospitals are now affiliated with 25 Walmart clinics. THe Cleveland Clinic has lent its name and backup services to a number of CVS clinics in northeastern Ohio. And the Mayo Clinic is operaing ne Express care clinic at asupermarke in Rochester, Minnesota, and asecond one at ashopping mall. This helps clear emergency rooms of people seeking bsic medical care as for astrep throat or flu. About one thousand clincs are operating in the US at drugstores, supermarkets and big stores since the idea took root 4 years ago. Wal-Mart has partnered with hopitals like the Christus Medical Group in Texas, Aurora Health System in Wisconsin and COxHealth in Missouri to setup clinics. Mayo did so after employees and patients said they wanted more convenient treatment for minor medical problems, so there may be a need here that as not been met. The lower costs at these centers compared to primary care doctors offices or emergency rooms make it possible for them to price lower and meet the needs of the 45 million or so uninsured people in the US, numbers growing as jobless rate increases. They are typically staffed by nurse practitioers or physicians asistants. Dr Herman at Mayo Clinic, who supervises its retail store clinics, says rather than fight this trend primary care doctors should learn from it, and work with hospitals around the country to offer more convenient locations and consumer friendly office hours, including periods of walk-in care with no appointment....

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Novartis is taking a new approach to drug research and drug discovery. The old one which was popular in the drug industry was to go directly for blockbuster drugs for large numbers of users, with a long time in the research pipeline because the area of research was largely an unknown. This was costly and becoming less and less productive. Dan Vasella who heads Novartis, is taking a different approach which comes from his understanding of medical science as a physician, in an industry run by accountants, lawyers and business people. This is to go after wellknown molecular pathways identified by Dr Fishman at Harvard in his research, and do this by taking on problems in diseases that afflict small numbers of people. These drugs have some established medical science to work with, and the research work takes a shorter period. Once the drug proves its effectiveness in one illness, it is tested for other illnesses that afflict a large number of people but which shares some of the same underlying phenomena that cause the disease in the two situations. Dr Vasella stumbled on this approach after the development of the drug Gleevec by Novartis. Gleevec was originally approved for a rare blood cancer, but has now shown to be effective against six other dieases. Gleevec brought 3.7 billion in revenues in 2008 for Novartis. In 2002 Vasella made a bold move to discard the old drug development model. The basis of this approach was to go after new drugs that were desperately needed and where the genetics of the illness were well understood. Whereas pursuing rare dieases is considered foolhardy by most drug company leaders, Vasella's idea is to use the common genetic underlying arrangements for that drug to go after other diseases that would be good prospects for the now proven drug. The known genetics makes it possible to complete the research in a shorter time. In 2009 Novartis has 93 drug candidates in the pipeline, 40% more than 3 years ago and 80% of Novartis' drugs last year made it from early testing to late stage development. This was a 60% improvement over 2005. The new approach fits the current regulatory climate, with regulators concerned more about safety, and Medicare and Medicaid and other payor less willing to pay for treatment with modest benefits or with uncertain outcomes. The approach had to be executed in terms of organization and staffing. Vasella moved the R&D global research operation from Basel to Cambridge, Massachusetts, and spent $4 billion on the move. He recruited a renowed researcher and cardiologist at Harvard University, Dr Mark Fishman, who had done research on the genetic mutations in the cardiovascular systems, to run the center and set the new direction for global research. Fishman convinced Vasella that medical research should focus on a small number of molecular pathways- the complex suquences of interactions among chemicals, proteins, and larger cell structures in the body that are behind all illnesses. Says Fishman, there are 24,000 genes in the genome, but only a few dozen pathways conserved through evolution. Fishman's theory is that you find all the links in a pathway and then locate the signals that can turn the genes on or off to develop medicines for illnesses. Bercause disease after disease share a common pathway, the knowledge gathered can then be applied across that region with more accuracy and directly, to address a range of illnesses. Fishman's approach means marketing and sales no longer make the decisions. There is a new method for doing things. Fishman focusses on clinical data and insists that commercial analysis comes after sufficient clinical data. A major restructuring in 2007 led to shedding 1260 sales and marketing jobs, as clinical science now takes precedence and medically trained scientists take senior leadership positions. The new approach is being used for a drug developed for Muckle-Wells syndrome. Computer simulations are shortening the time to late stage trials. The drug has applications for Type 2 diabetes and severe arthritis. The whole process will take many years, as its a sea change for the industry and for Novartis, a fresh approach when the approach used by the pharmaceutical industry for so long is failing. An oral drug treatment for multiple sclerosis is being developed along these lines. Afinitor. approved by the FDA for kidney cancer in March shows potential in six other diseases, including lymphoma where Afintor shrank tumors by 50% in one third of the patients in a trial. ...

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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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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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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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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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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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Krugman points out that the federal tax rate for the top 1% is 34% in 2013, according to the Congressional Budget Office, because president Obama let the high end Bush tax cuts to expire. It is the number to remember says Krugman- 34. In 2008 the figure was 28.2. Under Hillary Clinton the average tax rate for the top 1% would go up by 3.4 percentage points, according to the Tax Policy Center. Some of this would help pay for the tution plan to provide access to the middle class to public universities. Under populist Trump, Krugman points to the elimination of the inheritance tax and tax rates going down substantially, and no such programs to promote the upward mobility that everyone is talking about, and no way to pay for a big infrastructure building effort for growth and jobs- upward mobility that is the focus of every candidate's election campaign including Sanders, Trump in appealing to older white working class families, Clinton, Ryan, Bush, and others in both parties.   ...

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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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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.