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In this highly informative piece WSJ's Scism shows why buying long term care insurance policies in the U.S. in 2015 should be weighed carefully, because of large premium increases, and fewer insurers willing to sell such policies. The period of stays in nursing homes is shorter than previously estimated, with more men and women spending some time in nursing homes as they get beyond age 65. A Boston College study in 2014 shows men and women have 44% and 58% lifetime risk of needing nursing home care, higher than previous research, but the stays are much shorter 10 months and 16 months for men and women respectively. And 50% of nursing home stays for men, 36% for women do not exceed 3 months, giving them coverage under Medicare 100 day maximum for stays following hospitalizations. This changes the earlier calculations. About 8 million people have long term care insurance, according to Limra, a research firm, and 131,000 such policies were sold in 2014, down 24% from 2013, and way down from the 750,000 a year in the 2000s. A typical basic policy provides $164,000 in potential proceeds by paying a premium ranging from $1,685 to $2,813 for a 60 year old couple, according to the American Association for Long Term Care Insurance....

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This report in the NYT shows a grim reality that about 70% of 15400 nursing homes offering a place for the elderly in America are for profit and some owned by private investors who seek to turn a profit on the operations. With competition from home care support and assisted living facilities the investors were having a hard time turning a profit on the operations resulting in deterioration in quality of operations and care. 

 Japan, Scandinavian countries, and Germany, other countries have a better system for quality of life as people get older.

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Concern about the spread of the pandemic in the U.S. with the upcoming Thanksgiving holiday and travel to visit family and friends. Seen from Australia and other countries American fatigue with staying at home is cause for concern. Yet this is not entirely American as governments in France plan to have a phased reopening by Christmas, with phase 2 partial lifting of restrictions of the lockdown on December 15. Austria has turned down German requests to close Austrian ski resorts that have cause spread in Europe. The Swiss have also kept ski resorts open. During the summer Croatia and parts of Spain kept open tourist spots to help the economy recover creating the conditions for spread as tourists went back home. 

Beyond this there a complex web of choices. From mental health to hospitals filling up, from jobs and income for service workers to people in nursing homes, all calling for different responses. 

 

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Most people would not guess or recognize that this place where elderly people in society were treated shabbily is a country in northern Europe, and a country where citizens pay high taxes for precisely better healthcare across different age groups. Sweden is where about half of the 6000 people dead from coronavirus were elderly people.  Over the last two decades Sweden has cut hospital capacity and discouraged elderly people from entering hospitals during the early period of the pandemic, says this report in the NYT. The for profit nursing homes in the centre of Stockholm were unable to cope. Having turned the work in these homes to low wage workers, it put these workers and the elderly at risk with lack of staff, lack of adequate PPE oreven  basic masks, says this report in NYT.  One of the lessons of this pandemic is the failure not just in turning over manufacturing of health care equipment and pharmaceuticals to China, but also turning over the basic care of elderly to for profit institutions that were totally unprepared and could not give elderly the dignity and care they deserve. Year of cuts to public services and health services now showed in a glaring way what can happen when this is done. It has lessons for countries from Europe to North America, and to Latin America, India and other Asian countries as they redesign policy and allocate resources to public services in the next 10-20 years. ...

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Both sides have taken a pause in negotiations yet they are getting closer. There is also the conversation that we are not aware of that is taking place between McCarthy/McConnell and Biden about G7 leaders asking Biden on the debt talks. McCarthy will not want to affect the Ukraine counter offensive with all the talk about a debt default impacting the credibility of the US. McCarthy also could pass an agreement through the House with Democrats support with a small faction of Republicans not supporting him if push comes to shove and matters reach a critical point. By negotiating in good faith Biden is surely doing the right thing. The important thing is to let moderate Republicans have an opportunity to support him in the task of Renewal of America. The bigger task is 2024 which Biden has his eyes on, because this is how America will be made or unmade with the right choices and the right priorities. And Biden needs independents and Republicans who might consider supporting him to get things done for America's Renewal. House Speaker McCarthy's Republicans now support keeping spending at $1.65 trillion the 2023 levels. The Biden administration would consider a program of small cuts- no deep cuts. And only for 2 years. On work requirements for government aid to the poor and vulnerable Biden says he supported work requirements when he was a Senator in the US Congress. He outright excludes any work requirements for health benefits. Biden understands that in an economy with jobs going unfilled in construction and hospitality industries, and in child care and teaching, nursing, with higher minimum wages, people looking for work could find work to make a decent or tolerable living.   ...

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Young Korean-Americans in New York taking up American citizenship to avoid the draft in S. Korea, and a 108 year old Irish woman who immigrated in 1918 from Ireland. The Irish born Margaret lives at the Pine Nursing Home in Glens Falls, N.Y. She gave an interview to the Irish Voice, a midtown Manhattan weekly. She has never returned to Ireland since leaving Scariff, County Clare in 1902. In 1902 life expectancy in the US was 47 years! The percentage of Americans graduating from high school was 6%.

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

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Abbott is placed on a five year probationary period by the U.S. Justice Department. This comes after the $1.6 billion legal settlement for aggressive marketing practices to sell the drug Depakote in nursing homes.

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It can be a bit overwhelming, time for a pause, to close the Borders in Europe and in US, to do it together as a Nation. Republican Senator Lankford and senior members of Congress   negotiated the legislation to restrict immigration and close the southern border. It would be signed into law in January 2024 by Biden says Lankford in NYT after 30 years of inaction. The negotiated bill came up 2 months later in March by which time it was stopped by Trump Republicans as an issue for the election. Harris promise is to sign it into law, close the Border. Meanwhile in Springfield Ohio, population of 80,000 in 1960 declined to 59,000 in 2020 dropping 25% over the 60 year period with the decline of the Rust belt towns in the midwestern region of the US. A program that protects people from gang related violence in home country legally allowed 15,000 Haitian immigrants to settle in the city, people who now drive Amazon delivery vehicles and work in nursing occupations and in restaurants, in towns that have severe staff shortages. WIth the influx of refugees from Venezuela at the southern border, this has created anti-immigration sentiment in some parts of America, even as some of the refugees work to fill shortages in traditionally Republican states such as Kansas, as shown in the WSJ, that have decline in population and face severe staff shortages for bus drivers, restaurant workers, and hospital workers. Streams of refugees in earlier eras the Irish, followed by the Germans, followed by Blacks from the South, all followed this path, yet it was also a bit overwhelming, and at these times the nation took a pause. Europe is taking a pause- across Denmark, Sweden, France, the UK- and in the US there is sentiment on all sides for a long pause, to regroup, to reflect and focus on the national goals of binging up the middle class, the lower income classes, and the nation as a whole after the distortions from tech and economic theory induced distortions hurt the working people and families, and hurt rural areas. ...

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Stricter warnings on Amgen's Epogen and Aranesp, and J&J's Procrit, Anemia drugs.

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Two of Amgen's drugs that treat anemia in cancer and kidney-failure patients have questions raised about their safety and marketing. The two anemia drugs Epogen and Aranesp generate about half of Amgen's sales. THey now have ablack box warning placed on them by FDA requirements.

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Questions raised about Dr Pazdur's decisions at FDA for anemia drugs made by Amgen and Johnson and Johnson. Dr Pazdur is head of the FDA office that regulates oncology drugs, all cancer drugs. Dr Pazdur's review process and decision shows how reviewers are human and their own experience helps determine what they see prominently. His experience with his father who suffered severely from the side effects of steroid drugs would make him aware of the the other effects of drugs. He is an oncologist, his wife is an oncology nurse, and some relatives have died of cancer, so he has lived with cancer patients. It appears from close associates that he like open communication and hears all sides but makes the final decision himself. He had an experience with a drug for lung cancer Iressa made by Astra -Zeneca, which the FDA approved based on testimonials, but not enough statistical evidence, which later failed and approval had to be withdrawn. This may have made him more inclined to look for strong results and statistical evidence before concluding on the safety and effectivenes of a drug. An approach evident with Amgen's anemia drug. It also appears that the FDA is not clear on whether the drug's effectiveness is to be judged by what result, is it whether it prolongs life only that counts, or whether the effectiveness in relieving significantly the symptoms of a patient even if life is not prolonged. There is the controversy surrounding the FDA's rejection of a drug by Genta Inc Genasense that relieved patient symptoms for leukemia but did not prolong their life. These and other questions continue to give sleepless nights to people at the FDA and outside as the drug review process faces difficult balancing act between what to give importance and what direction to take with a drug in patient's interests. In Dr Pazdur's case this is made more difficult as he thinks every day of his father who died in 1979 and suffered from the side effects of steroid drugs, went blind when Dr Pazdur was only a teen, and had pulmonary fibrosis and diabetes. He is described by doctors who trained under him as gentle but did meet a patient's eyes and tell him that he had to come to terms with his disease. ...

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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. ...