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Lower oil prices in 2015 make it possible for president Joko Widodo of Indonesia to remove costly fuel subsidies in Jan. 2015. With the steep decline in oil prices this made it possible to lower fuel prices at the pump at the same time. The costly fuel subsidies cost Indonesia more than money spent on education and healthcare. This frees up money for other programs. In November the Widodo government fulfilled one of its election promises by sending out national "smart cards" to over 15 million poor Indonesian families, which gives them free health insurance and education related expenses for children for upto 12 years of school. Programs planned for infrastructure in 2015 include 13 new dams and long overdue upgrade to the north-south Trans Sumatra Highway. Critics point to the appointments, including for police chief and attorney general, that reflect the influence of Megawati Sukarnoputri, a former president and chairwoman of Mr. Joko's party, the Indonesian Democratic Party of Struggle, and of parties that supported Widodo. ...

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The U.S. House of Representatives votes to repeal and replace the Affordable care Act 217-213. Moderates were won over by an addition of $8 billion  to add coverage for a popular feature of the ACA that covered people for pre-existing conditions.  The bill that passed gives credits of $2000 to $4000 a year, depending mostly on age, upto $14,000 for a family. Credits are reduced for individuals making over $75,000 a year or families making over $150,000. There is no mandated insurance coverage. This trims the federal budget deficit, yet also is expected to keep 24 million more Americans without health coverage after 10 years. The bill now goes to the Senate where moderate Republicans are worried that this may increase premiums for older people, one of the drawbacks of the earlier version of the House Republican bill.

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Rising costs in the French health care system.

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Health insurance premiums for family plans increased by 9% in 2011 according to a survey by Kaiser Family Foundation. A similiar survey by Mercer showed premium increases around 6%. Another change is that health insurance plans are becoming less comprehensive and deductibles are higher, with higher copays and employees contributing more to premiums.

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Issues raised by the huge mismatch between revenues and investment for AI. $400 billion estimated investment by 5 Tech firms in 2025 alone with revenue of about $40 billion and huge uncertainty about when AI will produce returns. Articles seen this week of November 17 in the WSJ and NYT on this issue, podcasts, discussions in other media outlets. Could this lead to a dot com bubble type economic crisis? Could that lead to a recession? Alongside these articles another article in the WSJ on Nov 17 shows the benefits small firms get by using AI, benefits which are on the fringes of their business, not essential but with some experimenting firm owners/managers able to tweak AI information for use in business. Nothing significant which firms will pay much money for. The uncertainty is a major factor. Should geopolitics trump all these concerns? Is the competition with China require this scale of investment, and is China following a more utilitarian approach as reported in a WSJ article this month, of investing in AI in a utilitarian way targeting its use in improving manufacturing, improving infrastructure, and not wildly throwing money at experimental uses that are unlikely to yield much result. In geopolitical sense would the country that not only promoted AI but used it efficiently and cost effectively, used it in ways that promote the overall public good, get the WIN. In short it behooves everyone of us to ask hard questions of AI, to dehype the hype, to look for the public good that comes out of this from it's efficient use. To ask the tough questions when $400 billion generates only $40 billion in 2025 and the $3 trillion planned investment over 5 years is half unfunded, is it going to crowd out energy needs for homes and business, push renewable energy targets back, crowd out essential investments in the crumbling aging infrastructure of the US and Europe, crowd out essential investments in education, healthcare, pharmaceuticals, and manufacturing, that hold better promise for our People. Will it also put retirees at risk when corporate bonds from retirees money fund the unfunded portion of AI? This means making the political dimension not about migration, settling the illegal migration issue that was meant to be settled a long time back, or about cultural issues that have little day to day impact on our lives which are about groceries, childcare, housing that are non ideological. Making the political dimension not about remote countries that one knows little about except when it affects public safety and health as with fentanyl. Capital allocation decisions to the vital needs of America can then be free of politically induced error, so that it can be subjected to the test of how best it serves the public interest and the people of the Nation. ...

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The Congressional Budget Office analysis of the Republican healthcare plan advocated by Mr. McConnell, Senate Majority leader, is that it would add 22 million uninsured if implemented. That plan ran into opposition from Republican Senators Collins, Capito, Murkowski, Paul, and Moran, and lacked enough support in the Senate. All Democrats opposed it and with the thin majority Republicans were divided. By taking away some benefits given under the existing Affordable Care Act the plan hurt the elderly and low income people, making some Republicans listen to their constituents in home districts and not the Republican leadership. The NYT profiled two in particular who astonishingly in a sign of today's strange politics were the only ones publicly holding townhall type meetings to hear the views of people in their voting districts- Susan Collins of Maine and Jerry Moran of Kansas. Both senators were listening to rural communities and Moran stated his opposition with the words- "I am a product of rural Kansas." With it the nation takes a breather and the message goes out that it is best to listen first and then to seek middle ground, not do what both parties Democrats and Republicans did in 2009 and 2017- rush serious legislation through without support across party lines and without serious discussion.   ...

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Senators Mike Lee of Utah and Jerry Moran of Kansas declare their opposition to the Republican Health Care bill proposed by Senator McConnell. This decision by the two senators makes it impossible to begin debate on the bill. Earlier two other senators, Susan Collins of Maine and Rand Paul of Kentucky announced their opposition. This means the Republican health care bill has no chance in the Senate even after changes to the bill passed by the House of Representatives. Republicans have a thin majority in the Senate make it difficult to pass legislation. Collins met with residents in Maine and Moran with people in his home state of Kansas, and both senators heard a lot about the negative effects of the Republican bill on people in their state. The bill is seen as hurting people in rural areas, elderly, and not likely to do enough to bring down premiums. Its plan to slash Medicaid spending has drawn strong opposition from all Democrats.

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This story in the NYT describes how the flawed effort to pass the Republican healthcare bill or repeal the Affordable Care Act passed under president Obama failed after another effort. Many developments killed it. In the end the president lost interest, especially when he saw Republican Senator Rand Paul of Kentucky go on talk shows on the weekend before its collapse to complain about the bill. Senator Collins of Maine was exasperated by the way the bill was being rushed through Congress, and she voiced her strong opinions about this by talking to people back home in Maine and sharing her conversations with the media. The bill pushed by Senator McConnell, the Republican leader in the Senate, imposed annual caps on Medicaid spending. And did this without any discussion, shutting out committee debate, any public discussion, or formal drafting. Once this process was set in motion in this way the Republican Senators formed camps. Senator Grassley of Iowa and Jerry Moran of Kansas, normally conservative moved to the moderate side. Moran held a town hall meeting covered in the NYT, where older people voiced their concerns. Most of the patient advocacy groups, the hospital groups such as the American Hospital Association, and other medical groups also opposed it.  After Senator McCain of Arizona said he could not return following a surgery in Phoenix, Senators Lee and Moran announced their opposition. With this the bill's support crumbled including any effort to repeal the Affordable Care Act.  ...

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Ken Murray, a retired family medicine professor at the University of Southern California, describes how doctors address the option of prolonging life when the prospects of survival improve say from 5% to 15%. The choice is based on the human need to find closure in an atmosphere that gives comfort, a sense of peace and a sense of place with home and family, with hospitals not deisnged to and not able to perform that role. Murray gives the example of his cousin Torch, who he says was born at home by the light of a flashlight, who decides to not choose aggressive treatment, which would have prolonged his life for no more than 4 months. Instead he spent the next 8 months with family and did everything he could do with the 8 months that made for quality of life, rather than just choosing quantity in and out of hospitals. He died peacefully in his sleep. The heroics in and out of hospitals would actually have deprived the patient of the opportunity to reach a sense of closure that comes from the comfort of home, family, and arriving at a sense of peace....

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Biden calls ending the war in Afghnistan a "wise decision" for the American people. He says in his foreign policy speech that "it is about ending an era of major military operations to remake other countries." A Pew Research poll shows 54% of American adults support the decision.  In a sense the decision had already been made. Biden cited the Doha agreement president Trump signed a year ago with Taliban that called for the release of 5000 Taliban prisoners which included most of the top commanders, and no agreement on the future of Afghanistan. The decision had come much earlier than that when the wars in Iraq and Afghanistan from the period of George Bush were rejected by the American people for the cost and lack of purpose during the presidential election of 2016. That period marked the rejection of policies set under Reagan, Bush and Obama for starting American involvement in the Iraq-Iran conflict first on one side and then on the other side. All the time precious resources that were needed for infrastructure and services in education and healthcare were diverted to these wars, impoverishing America and also Europe. Looking beyond the words thrown around for political advantage both Trump and Biden and the American people, had decided to put these wars behind them 5-10 years earlier. Biden said assertively that America had made a tragic wrong turn, that was all he could say about Reagan, Bush, Obama policy. In the meantime he stated something else was happening- the US was losing its position in the world by wasting its resources in these wars that do not serve the interests of America. "There is nothing China and Russia would want more in this competition than the US to be bogged down for another ten years in these wars."  Biden was saying that he had the courage and tenacity to make a decision that was the right one and a wise one for America against all the transient opinion of people who lacked a grasp of what was happening to the American people- the increasing impoverishing of America in both rural and urban areas. And a similar situation in Europe. It was time to take a new turn, close this chapter, and write a new one in American history, brighter and with new sense of hope. ...

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The $350 billon in proposed cuts to Medicare and Medicaid in the 2011 deficit reduction talks will do little to reduce the rapid rise in medical costs. Instead it shifts the costs to seniors, state governments and public hospitals. Gail Wilensky, former head of Medicare under the first President Bush and now a senior fellow at Project Hope, says this should not be confused with real reform to Medicare which reduces the rapid increase in costs. It does little in the way of fundamental changes that would reduce the growth in costs. About $53 billion comes from reductions to senior's ability to buy extra Medicare supplemental insurance or Medigap. Another $14-26 billion would have the government reduce payments to hospitals for unpaid debt. The few items to curtail fraud in the use of CT scans or purchase of power wheelchairs would provide savings of $2-3 billion over 10 years. $4 billion comes from lowering Medicaid payments to hospitals treating a high percentage of low income patients, hospitals such as Cook County Hospital in Chicago, San Francisco General Hospital, and Parkland Hospital in Dallas....

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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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Serious problem of rapid premium increases for middle class people not eligible for subsidies under the Affordable Care Act. Insurance companies have increased premiums rapidly to pay for the cost of treating people with previous conditions and the uninsured, as well as population with poor health conditions.

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Gerald Seib of the WSJ points out that the winners in the passing of the Republican healthcare bill in the House by a 4 vote margin are Speaker Ryan who never wanted the job in the first place, and president Trump who showed he could cajole Republicans into getting it passed because he likes winning. Now comes the hard part says Seib, when it goes to the Senate- House conservatives are not going to be happy when they find major changes they dislike. If the bill clears the Senate in a modified version Republicans will now have to own any issues with healthcare, including says Seib things that may not work out for pre-existing conditions- or for groups that are disadvantaged, including older people.

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The EU's competition commissioner to crackdown on pharmaceutical companies that are delaying the entry of generics drugs with various tactics that are anticompetitive. EU has raided the offices of several marge drug companies and retrieved documents that show this activity was going on. About 5% of medical bills or 3 billion euros coud have been saved from 2000 to 2007, if companies had allowed generics to enter the market earlier and not resorted to these antitcompeitive strategies. Like paying off generics companies or having so many patents on the ingredients of the drug, in one case 1300 patents on one single drug, and then suing the generics companies to tie up the case in the courts.

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Business Week's Chad Terhune points out that the health reform bill that passed Congress will do little to restrain the overbilling by pharmaceutical companies, medical device and equipment makers. Chad cites numbers from the U.S. Health and Human Services Department that shows $47 billion in Medicare spending went to dubious claims in the year ending Sept 30, 2009. This is 10% of the $440 billion Medicare program. And 10% of the Medicaid program also goes to dubious claims. Consider then that Congres allocated $10 million annual increase to fight fraud. A suit filed by a former Siemens manager at the federal court in Philadelphia states that Siemens routinely overbilled the Veterans Affairs Department and other governmental agencies by humndreds of millions of dollars for MRI and CT scan machines.

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With the rushed approach adopted by the Trump administration not enough consideration was given to winning support in the House from 25 conservatives in the Freedom Caucus. Without their support the bill cannot be passed in the House of Representatives. The fight also includes one over what are essential health benefits including whether  maternity care would be included. As a result some moderate Republicans are also expressing opposition on the grounds that less people will be covered and fewer benefits will be provided under the Republican House plan called AHCA. President Trump has not involved himself in the details, and the bill comes very early in the first 100 days, leading to the perception that health care has become a partisan conflict without really grappling with the problems of high cost of health care and creating a solution that all can support. Democrats are seen as having made the same error early in Obama administration's first term. President Trump sees this as a much needed win with a drop in his approval ratings, making this even less of an effort to come out with a good plan.  ...

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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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Susan Jaccoby brings up a major issue facing healthcare in America from personal experience. A third of the Medicare budget, she says, goes to the last year of life, and a third of this goes to the care in the last month. At the same time public opinion polls show Americans see the problem being too much medical intervention rather than too little. Especially when there is no hope except to prolong life for the patient with an highly deteriorated qulaity of life for a few months or a year, doing no service to the patient or future generations who may see their basic services cut when they most need it as a result of the unaffordable spiralling cost of Medicare. A Pew Research Center poll in 2006, shows 22 percent say a doctor should not always make efforts to save a sick person's life, and 70 percent believe that patients should be allowed to die in some situations, when it only prolongs life for a few months for instance and patients live in pain. The problem only gets worse in future years as an estimated 8.5 million Americans are expected to be over 85 years in 2030 with these same choices facing patients, their families, Medicare and the country....