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The influence of lobbyist on members of Congress just as the Obama administration, having studied the failure of the Clinton submitted healthcare plan try a different strategy of letting Congress come up with a healtcare plan. $133 million was spent in the second quarter alone by healthcare industry lobby interests creating headaches for reform efforts and the Obama administration.

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What does transformational liberalism mean? What does fairness mean? What does it mean to have unemployment insurance, to have health care, to have jobs, to open the door to the middle class for a college education. Is this transformational liberalism? Or is this "transformational liberalism" a part of a vocabulary of cliches that have lost meaning as the nation confronts job losses of the magnitude of 500,000 a month, and this is only the beginning. Much of the increased debt the nation is occurring is going to provide government help to financial institutions like the $177 billion that has gone to AIG so far, just one company, and there are the Citigroups and other companies like AIG. What does it mean to have "burden sharing," when the rest of the country is frightened, scared, losing jobs, losing savings, and at this juncture cliches may have lost meaning, as its those who profited most and got us into this crisis like the investment bankers and senior management of companies in industries like the mortgage industry, auto industry who will be paying their larger share not because of redistribution, but because they may be the ones who can most bear this burden wihtout great sacrifices like cutting down on necessities and basics. See the link to Countrywide's Kurland who plans to profit both by overselling mortgages and creating the tinder that started this fire, and now to profit by buying distressed properties at pennies on the dollar, with $200 million from Black Rock as an investor, and $200 million on stock he sold before the crisis. Is a Kurland who has not been subject to any regulatory action, or management of AIG, or Citigroup or GM or the other companies receiving federal money by the hundreds of billions of dollars about to ask the half amillion of unemployed and the others threatened with job loss each month, for "burden sharing"? Nobody wants to see any of this happen, what has happened, including the debt, but it has happened, and it was not engineered in the new budget or in the few weeks since early January 2009....

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The Congressional Budget Office's Elmendorf says without spending cuts in payments to doctors and hospitals and other providers, providing coverage to the unisured will put the nation deeper into debt. Popular measures such as increasing preventative care, expanding medical records and rewarding doctors for choosing treatments that improve cost and quality have potential but its not proven how much the savings from this would be. The administration and the White House Budget Director, Peter Orszag, say they are in agreement with the CBO that something needs to be done to seriously reduce costs, reducing payments for Medicare and Medicaid to doctors and hospitals, and making other changes.

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Walgreens is changing its growth model to add the business of Health and Wellness buying two companies I-trax Inc. and Whole Health Management which run 350 health centres at corporate offices. Pharmacies will be added to these centres. Its targeting 7600 office sites with 1000 or more employees that could use a health-care center. Its competitors CVS and Walmart are going into managing employer drug benefit programs, with Walmart's selling point being reducing costs of paying for prescriptions for employers.

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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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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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The language and tone of the leaders says something about what is likely to be the outcome of the G20 summit. Its a first for significant participation, as countries as diverse as Russia, China, India, Indonesia, Saudi Arabia, and the Netherlands are represented. The credible positions of both sides, the US, UK and Japan, and the European side of France, Germany and the Czech Republic, well presented, provide for some serious discussion and negotiations. France's Sarkozy and Germany's Merkel want to see a global regulator that would reach inside the borders of the US with stricter regulation. Sarkozy calls this "nonnegotiable." And he said that he would reject an agreement that puts off stringent new regulations on banks, tax havens, and hedge funds. He said "the compromise has to come from all countries around the world." US President Obama said that if there is going to be renewed growth it can't just be the US as the engine, everybody is going to have to pick up the pace," at the same time saying that the US had to be concerned about its own deficits. The fact is that the US stimulus will mostly help a severely impacted domestic economy recover with social safey net payments to local and state governments and unemployment insurance, as well as targeted investments in infrastructure, education, energy and health care. It will not mean anywhere near the kinds of imports the US made from other countries, especially China. And Obama made that clear when he said the US will never return to that situation, where the US had become a "voracious consumer market." For the Germans the major market for their middle companies is China, and China has its own stimulus spending on infrastructure spending, which should provide for continued imports of machinery from Germany at a much lower level. Thus Germany and France see a strong tendency to call the source of the crisis and repeat that call till the US listens, and refer to the failure of free market capitalism in its unregulated form. And to insist on fixing it through a global regulator with strict and systemwide rules. So you hear this in Merkel's words, "the foundation for this finacial architecture must be laid now, that is why we seem to be so tough." While the vivacious Sarkozy talks of compromise, and a US gesture in regulation in return for Franc's gesture of joining NATO, the mild mannered Merkel is clear and focussed about her concern. She rejects the idea of linking stimulus spending demands of the Anglo-Americans with the Franco-German demands for global systemwide regulation. "This is not a bargaining chip," she says. The media may mistakenly report lack of consensus as a failure of the summit. But in the long run in the presence of good positions on both sides, it could lead to some tough negotiations even if continued at another meeting. And result in something serious, credible and lasting in its impact, rather than something that was easy and did not in Andy Grove's useful words involve "constructive confrontation." ...

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A new report by Medicare trustees found that the Medicare hospital trust fund would face insolvency by 2029, which is 12 years after the projection made last year. But Medicare's chief actuary questioned this by saying that this assumes cuts in payments to medical providers in the health reform bill would be implemented. Not realistic he says, considering that many doctors would drop out of Medicare causing difficulty for seniors. After 2029 Medicare would be able to pay 85% of the benefits according to this report. Separately the Social Security fund is expected to need a $41 billion cash infusion, with more paid out in benefits, than collected in tax receipts in 2010 and 2011, with this situation getting worse by 2015.

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Doctors face a 21% cut in the amount of Medicare payments for treating seniors having Medicare, though this cut will be delayed till 2011 under legislation in Congress. This issue goes back to 1997, when a budget law set spending targets, and stated that if they were exceeded formulas to reduce doctors payments would go into effect. The formulas seriously cut into doctor payments by Medicare in 2002, so the formula was put off. The result of this is that the cuts based on the formula now amount to 21%. The cuts are not expected to go through, but at the same time Congress has an headache on its hands with the growing deficit. In the Senate there is opposition to a $120 billion bill to extend long term unemployment benefits which lapsed in June 2010, for tax breaks, and other expenses. Senators want to pare down the bill's price tag, as $80 billon of this is unfunded and will be added to the budget deficit. For a primary care doctor in Washington state, Medicare pays about $95 compared to private insurers payment of $129, and a plan for state workers that pays $140....

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Tyler Cowen, Professor of Economics at George Mason University, points out some basic truths about health care as it is practiced today in the USA, and healthcare spending as it stands today. He questions whether starting out with extra spending plans to provide coverage to all will help solve the basic problems facing American health care. Too many tests and diagnostic procedures used by doctors is not aproblem that will be solved by spending more money to cover everyone. And government taking on more spending to cover all will not address all the other major shortcomings of the American way of practicing medicine, like prescribing a battery of tests, that tend to drive up costs, to just mention one of the problems. And it will not address any of the shortcomings in the way Americans take care of their health, diet, exercize and healthy lifestyles. THese are critical to get good health outcomes for the people, and which combined with careful spending of dollars where it will provide the greatest benefit, is the only way the health care solutions can be found....

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The worst flaw in the health care bill says the Economist is that "fee for service" and doctors billing for each test done continues as before.The whole idea of medical services based on medical necessity and value for money has been left out of the billsin Congress. Alan Meltzer also pointed this out in his discussion of the deficits and debt over the next decade; that the 25% reduction in medical expenditures does not look anywhere closer to reality, worsening the deficits. This is also the view expressed in the discussion of health care reform in the November 2, 2009, issue of Business Week. Never mind said BW that the doctors and hospitals account for one third of medical expenditures and there is waste in Medicare spending. Congress said BW has made no changes in the "fee-for-service" system of medical care that has inflated medical costs, by paying doctors for the volume of services delivered and not the quality of services delivered.

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The influence of the AMA convened Relative Value Scale Update Committee (RUC) on how the Medicare payments to doctors is shared, and on the growth of the Medicare budget. Concern that the interested party is driving the decision making process. Medicare costs went up by 9% in 2009. Fears that doctors have too much control over the dollars in the $500 billion Medicare program. The tendency to focus on more expensive procedures and short change preventive and less costly care. Medicare spends $60 billion on doctors fees. The older codes remain in place even when costs are reduced, leading to higher costs for the Medicare budget each year. And there is little incentive for doctors in RUC to revise overvalued codes.

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Are there costs or are there savings from the Obama health care bill? Does it affect jobs and how? The Congressional Budget Office says the health care law will save $230 billion in ten years based on a whole set of calculations and assumptions. Commonsense and basic math leads others to question how spending $930 billion on insuring 32 million Americans could end up with significant savings. The different view argues that the Budget Office erred in making some calculations, by counting $70 billion in premiums from long term care because they would be used to pay benefits later, omitted $115 billion in spending to adminster the law, and omitted $208 billion needed to prevent scheduled reductions in Medicare payments to doctors. The money needed on the Stimulus, on two wars in Iraq and Afghanistan, and the uncertain prospects of the US economy in the longer term till debt and other issues are resolved, injects the critical element of difficult choices and priorities. If state and local budgets are severely strained in 2011-2012 would that require federal help and will there be other needs that will have to be met by the federal government that are critical such as another unexpected downturn, or a resolution of unresolved bad debt at the large US banks There is also a sense that the health care law does not do enough to reduce the cost of health care that will be needed over the next decade so that other priorities are not neglected. Both parties are not up to the task in this respect for running the country's finances withot using the numbers to tell different stories....

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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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Estimates show the 50 million Americans enrolled in Medicare today will increase to 80 million by 2030, according to the program's actuaries. Simple demographics as the baby boom generation ages is making controlling the deficit without controlling increase in health care costs as both sides in the fiscal cliff negotiations are attempting to do can only lead to defunding critical areas such as education, R&D and infrastructure, and breaching the safety net for lower income Americans. Health care spending took up 7% of GDP in 1960, increasing to 17.9% of GDP in 2010. Federal spending on healthcare has grown to about 25% in 2012 from 10% in 1960, and is projected to increase to about 33% in ten years by the Congressional Budget Office.

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The basic problems facing American health care. Douglas Elmendorf , head of the Congressional Budget Office, says none of the bills he has seen make the fundamental changes needed in how medical care is delivered and paid for. The big issue is the unwilingness of different interests to accept serious changes. THe NYT says the long run solution to the problem of rising costs is to move away from the fee-for-service system that pays hospitals and doctors for each additional service they provide and into anew system that is organized around ways that encourage low-cost and high quality healthcare. The difficulty is that the long run may be too far, considering the seriousness of the crisis. Elmendor also suggests taxing employer provided health benefits, as this will discourage the excessive use of medical care. As the NYT says this is politically risky, even though it believes this may be a way to the new system which has to discourage the use of health care in the manner it is conducted now, with too many tests being conducted. A new system requires an enlightened approach on the part of each interest group in the face of a crisis, and the failure to do that may only end up retaining some of the worst aspects of the old system just mentioned that drive up costs and make universal health care unaffordable....

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Alan Blinder, Princeton University professor and former vice chairman of the Federal Reserve, says the biggest reason for the growing deficit in the years out to 2040 is because of increases in health care spending. Its not that there is runaway spending in other areas. He cites CBO projections that show other costs stable relative to GDP from 2015 to 2035 and declining. This is why healthcare spending is at the heart of the problem. And why tackling the deficit has a lot to do with reducing healthcare cost increases.

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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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Obama cites "Seneca Falls and Selma and Stonewall" in his second inaugural address after failing to push strongly enough to address poverty and civil rights, housing foreclosures impact on minorities, and immigration during his first term. Stevenson says the address was filled with King's "urgency of the now," in pushing for progressive values in an unabashed manner. Freed from the constraints of the first term Obama senses the urgency of the moment if he is not to lose the opportunity to have contributed to the march of progressive values in America during his term as president. A cautious president feels the urgency of the progressive spirit that marked his early years, his first book, his work as a community activist and Illinois legislator; if all this is not to be lost in the burdens of the presidency, the pressures of politics, the fundraising machinery, election manoeuvring and vote getting that secured the presidency.

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Seib points to the part of the president's inaugural speech that said action must be taken even if victories are partial, that the debates over the role of government could go on for all time, but action however imperfect needs to be taken in this time. There is a sure willingness to engage in more partisan fights with Republicans and a broader list of issues from climate change to immigration, gender equality and curbing guns. The diffusion of the pent up purposes- pentup by the first term economic and healthcare issues- and the short time during the second term of 2 years to accomplish this, adds to the urgency for the president Obama.

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The US is facing a new pattern of demographic changes and their impact on Medicare and Social Security programs. The number of people on Medicare will grow in 2 decades, 2010- 2030, from 47 million to 80 million for Medicare, and from 44 million to 73 million for Social Security, according to this estimate. The workforce will grow more slowly and the tax base wiill shrink accordingly during this period. This pending worker-pensioner imbalance and the jump in the cost of the bill for Medicare and Medicaid, as well as the federal health benefit for poor people, create a major problem for the US. At the same time the group of people over 65 will rise in these 2 decades from 17% of the voting age population to 26%. This group and the people who expect to soon join this group will resist any changes to Medicare or Social Security programs, making it that much harder for the political process to tackle these issues to make the programs sustainable in the long run.

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Alan Simpson of the Bowles-Simpson Commission describes the task the super-committee faces in coming up with $1.2 trillion in savings for deficit reduction under the recently passed legislation.