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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 Washington Post survey of 1200 readers on how the Republican healthcare plan of Speaker Ryan and the House of Representatives looks to them, how it affects them in their lives. Here Somasekhar of the Post gives the stories of 5 Americans. Some see the prospect of losing their insurance under the Republican plan even as they reach an older age, others a smaller segment says the Post, whose premiums jumped under the Affordable Care Act say they faced high premiums and high deductibles. The Post says the large majority of opinions have expressed anxiety over the proposed Republican Ryan House plan for healthcare. One of them is an uninsured poor farmer, Mr. Woosley,  income about $18000 who gained benefit from expanded Medicaid under the Affordable Care Act,  one Mr. Smith, 32 years, a personal injury attorney who faces paying $10,000 if he did not take insurance and $10,000 if he took insurance because of high premiums so a wash either way deciding to do without it, one a tech worker Mrs. Powers, 62 years, income $22,000 on year and $4000 the next, from middle class during the tech boom but facing fewer opportunities and uncertain income from part time work, hit by the deep recession facing fewer opportunities as she gets older and now the prospect of losing insurance without government subsidies, one who is from the middle class who sees little benefit from the Affordable Care Act and is forgoing insurance because of the high premiums yet faces a penalty for not being insured under the ACA, another Mr. Blanchard, 52 years, is from the middle class, a computer programmer who lost his job in downsizing, earns $100,000 as a consultant self-employed, pays $767 in premium a month and relies on the Affordable Care Act which helps him gain freedom from working at a company that could downsize,  another is a middle class programmer Mr Riffle,age 44, and his wife, who does not qualify for a subsidy with a $71,000 family salary from working 4 jobs between himself and his wife- this person finds it too expensive for his salary to buy insurance $900 a month and $14,000 deductible under the Affordable Care Act. His views are worth listening to as they go to the crux of the problem- he says he may not be any better with the Republican plan. He sees the real problem as the high cost of health care in the U.S. and the only way this can be fixed is for members of Congress to be asked to use the insurance exchanges they create. If this sample is representative it shows that there are real problems with both the Affordable Care Act and the Republican plan, that the high cost of health care the problem lurking behind every plan that does not squarely address this, and till that happens and members of Congress experience what ordinary people face, this problem can never by fully solved.   Woosley, Smith, Powers, Blanchard, Riffle, and their personal experience is at the crux of what is right and wrong  with the Affordable Care Act, and also with the new Republican plan of Speaker Ryan and the House of Representatives. For every Woosley, Powers and Blanchard who benefit, there is a Smith and a Riffle who are indifferent or are affected by the high cost under Affordable Care Act and the current system of medical care with its high cost. The Affordable Care Act does not  tackle high cost, for that to happen the culture in America that makes it possible and acceptable to charge high prices must change. Another problem apart from bringing health care costs is that any solution needs to have the whole country behind it. If the notion that all people are entitled to basic health care is to stand, the whole country needs to believe it as they do in countries like France, Britain, Germany and Japan. If this has to be made a workable proposition health care has to be offered at a price that makes this possible to achieve, and that idea also needs the deep and broad sense of support from the culture in America similar to that in these other countries. Until that happens politicians in America will get elected and turned out of office in turns on issues such as health care, based on which side they take and which problems they choose not to face squarely and responsibly. ...

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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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David Wessel points to some problems with the Paul Ryan budget proposal. Ryan's plan does not balance the budget till after 2030, and Congress would have to raise the debt ceiling each year till then. The changes to Medicare Ryan proposes would limit how much the government spends, but the savings from this do not come for a decade, as people expected to retire in the next 10 years will still have Medicare. Ryan's proposal shows how deep the cuts will have to be if deficit reduction is done without raising taxes. Pete Domenici and Alice Rivlin who developed a deficit reduction plan, said they were disappointed that the Ryan plan "fails to address the need for new revenue," which they consider crucial for truly tackling deficit reduction. The Obama budget failed to offer a comprehensive deficit reduction plan, leading to openness for new ideas. The health care delivery system in the U.S. needs to be efficient and costs need to come down. Ryan's proposal gives no idea where the efficiencies will come from. Would they come from competition between private insurers? How will escalating healthcare costs be controlled. Another consideration is that even with its problems Medicare is less costly to administer than private insurance. Everything depends on seniors shopping vigorously for the best premiums because risks and costs are borne by seniors, with the idea that this will somehow control escalating medical costs....

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Rappaport of the NYT asks how it is possible that the U.S. Treasury is critical of the EU Commission's ruling that Apple pay back $13 billion in taxes because of its low tax rate of .005% in Europe, when Treasury is strongly critical of tax avoidance. The negligible tax by Ireland, base of Apple operations, is seen as a state subsidy not available to competitors. It also, as the EU Commission says, does not correspond to economic reality because the revenues are mostly made outside Ireland. An arrangement that is basically a strategy of tax avoidance. Today the leading candidates for president, Trump and Clinton, the major parties, and Congress, all are critical of tax avoidance strategies which deprive Treasury of much needed revenues. Restoring upward mobility is a priority today and programs to provide tution free access to public colleges, healthcare access, and infrastructure development, require public funding. Then why is the U.S.Treasury critical of the EU ruling? It is because Treasury sees this as money that should be coming to Treasury not the EU. However Treasury has failed to make this clear. The Financial Accountability and Corporate Transparency Coalition's Clark Gascoigne, calls it very ironic. And other experts say the money would not be coming to the U.S. anyway unless a low tax rate induces Apple to repatriate profits to the U.S. One expert calls it hypocritical. Senator Schumer says he agrees with Paul Ryan that tax legislation for a low tax rate for repatriation of profits back to the U.S. should be the next step, so that an infrastructure fund can be setup. Senator Levin and transparency advocates sees the EU action as normal and to be expected, as the anti-establishment sentiment today comes from such dealings that create the impression that the system is rigged in favor of some corporations. ...

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The 2016 primaries with Sanders and Trump have brought to the forefront voter dissatisfaction with the agenda of both parties, especially so for Republicans with the lack of specifics and personality driven campaign of frontrunner Trump. On a whole host of issues from poverty, wages and inequality, regulatory reform, to trade, borders, security, ISIS, both parties are facing questions from voters. Particularly the Republicans who have lacked specifics during the two terms of the Democratic Obama administration with a divided Republican Congress, and the risks for Republicans running for Congress under frontrunners Trump or Cruz who have provided few details on their agenda. The Agenda project of Ryan will have about 25 meetings and prepared specific agenda, including white papers and legislation, that would give Republicans hope to run on positive proposals that are placed before the Republican Convention in Cleveland. Chairmen of House standing committees were assigned 6 areas- health care, taxes, national security, regulatory reform, poverty, and Congress reasserting constitutional authority. Ryan told the Ethics and Public Policy Center on April 19, 2016- "A lot of people don't like conservatism as they know it. For too many people Republicans seem to be caught in a time warp. They're thinking, 'We don't control our borders. Wages are going nowhere. College and healthcare keep getting expensive. ISIS continues to spread. And what are Republicans going to do about it?' So we need to adapt our policies to meet the challenges of the 21st century."...

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Allan Blinder gives a spirited account of what he sees in the Paul Ryan Republican deficit reduction plan. He says that with the voucher plan retirees would fall further and further behind the increasing cost of health insurance. With no explicit cost containment proposals it assumes that some kind of miracle will occur for costs to be kept in check- especially as Republicans want to repeal the cost containment proposals in the President's healthcare plan. He asks whether someone is saying, that we have to destroy Medicare so it can be saved. Ryan woulld also turn Medicaid into a block grant, then underfund it and let the states figure it out when they are in a budget squeeze. Blinder points to the estimates of the Center on Budget and Policy Priorities, that show about two-thirds of Ryan's budget cuts would come from programs that serve low and moderate income Americans. And to make matters worse the steep spending cuts go to finance tax cuts that largely benefit the wealthy. He calls this Robin Hood operating in reverse, and coming on top of 30 plus years of rising inequality. David Stockman makes a similiar point on the editorial pages of the New York Times, April 24, 2011; also adding the point that the middle class will have to pay higher taxes for the deficit to be addressed, something President Obama's plan fails to do. Blinder says that the Bowles-Simpson and Rivlin -Domenici proposals attack the deficit reduction problem in a better way, that asks something from all classes and interests. ...

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In this insightful essay Peggy Noonan, former spokesperson for president Reagan, says that Republicans like Speaker Ryan with the Republican Health Care bill are making the same error made by president Obama.. Noonan says she had suggested a different way for president Obama to show compassion for the uninsured- first wait till the 2008 financial crisis was tackled, tackled waste and fraud in Medicare first, then look at the option of expanding Medicare to help the uninsured, and not the approach taken of swiftly focussing on the Affordable Care Act early in the first term disregarding Republican objections. She says Republicans are making the same mistake now by ignoring the impact the bill would have on Trump's base of working class Americans who may be affected by the bill's provisions not taking into account incomes in offering incentives or subsidies. Noonan says Trump did get one thing right in calling it a "carnage" for the worsening opioid epidemic in America which has hit rural areas and parts of the midwest hard. Noonan says Eberstadt has correctly documented the collapse in working class Americans wages and standard of living, and Caldwell the opioid epidemic at another level to their health. She also supports journalist Carlson who questioned Speaker Paul Ryan's judgement about eliminating the tax on wealthy investors in new legislation in a Fox News interview, as she says responding to the sense of America at the moment means listening to the sense of being left out of ordinary Americans, who have done not as well as the wealthy who have benefitted from a surging stock market.  ...

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The major provisions of the Republican House healthcare bill that passed by a vote of 217-213 are- 1. To help people buy insurance coverage the bill offers $2000 to $4000 a year, upto $14,000 a year in credits based mainly on age, reducing them for families making $150,000, individuals making $75,000. 2.  Under the Affordable Care Act insurers cannot charge older Americans more than 3 times for same coverage they offer to younger people, the new bill makes this 5 times. This would increase premiums for older Americans and reduce it for younger Americans. This is the most controversial part of the bill. Older Americans supported the Republican party in the presidential election. 3. The new bill ends Medicaid as an open ended entitlement and places this on a budget with cuts of $880 billion over 10 years. 4. To mollify conservative Republicans a provision allows state to opt out some provisions of the ACA that requires minimum benefits such as maternity care and emergency services. It retains coverage for pre-existing conditions to mollify moderate Republicans. The bill provides states with $138 billion over 10 years to subsidize premiums, provide coverage for pre-existing conditions, mental healthcare and drug addiction. 5. The bill removes the taxes imposed under the Affordable Care Act (ACA) on high income people of about $300 billion over 10 years by repealing a payroll tax increase and tax on investment income. This bill and the ACA offer 2 competing visions on healthcare, both bills passed only by a margin of 4-5 votes in the House. The ACA overlooked the impact on premiums causing discontent among middle income Americans. The new bill lets premiums rise for older Americans in order to keep premiums down for other Americans. This shows the many tradeoffs involved and choices being made, and the lack of a consensus on the issue of healthcare in the U.S., becoming a highly politicized issue instead of the way it is treated in western Europe.     ...

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This NYT editorial points out that the cuts to Medicaid amount to taking out a fourth of its budget and are sure to hurt low income Americans. The cuts are about $880 billion over 10 years for Medicaid. The $300 billion less in subsidies over ten years is likely to hurt the elderly. It also points out that removing the individual mandate will make it harder to reduce premiums as fewer healthy adults offset the costs of sick patients.

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The positive influence for the Romney campaign on conservatives, independents, seniors and working class voters of the selection of Paul Ryan. Ryan gives a well received speech at the Republican convention in Tampa, at one point referring to college graduates facing a tough job market "staring up at fading Obama posters."

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The coverage of the Republican healthcare bill and how it affects the elderly, and people on Medicaid, people in rural areas, is likely to have changed public opinion in the U.S. about the necessity of ensuring all Americans have health coverage. The Pew survey cited here in this NYT report by Zernike and Goodnough was done in Jan 2017, and shows a shift. The shift would be much higher today after people look hard at the consequences of what were simply hypothetical positions or ideological positions taken without looking at consequences in daily living. On Medicaid that opinion by July 2017 compared to Jan 2017 has shifted 10 percentage points for Republicans to 53% who think Medicaid is important to them and their families, according to Kaiser research. There is stronger sentiment about people having benefits taken away.  [article-55059] The opinion has shifted to where people see that coverage is important and people should not have coverage denied or benefits taken away from them. Opinion remains strong in favor of changes to reduce the high premiums, but not to replace the existing health benefits and law with no law at all to replace it. That leaves 20 million more uninsured according to the Congressional Budget Office. Changes have to be constructive is the popular view today,  and this requires dialogue between Republicans and Democrats- which has not taken place. ...

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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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The distrust in negotiations between Republicans Boehner, Ryan, Cantor and Democrats Reid, Obama, and Pelosi, during the weeks in October 2013 preceding the reopening of U.S. government after the shutdown. Republicans call attention to the rising deficit from $4.9 trillion in 1993 compared to $16.7 trillion in 2013, triple the increase in the deficit in just one decade compared to the five decades prior to this period. Democrats say sharp spending cuts would hurt economic growth and the unemployed.

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The tech boom bust since 2000 that has hurt America and Europe and which also laid the foundations for the loss of manufacturing and technology to China, ceding American leadership and critical advantage, is shown here in the WSJ. The role of the finance sector  is explained here. That has added one more factor to the factor of endless wars in the Middle East, where American and European investment in healthcare, education and new infrastructure was somehow diverted away, and much of America's and Europe's resources wasted- or not turned to the benefit of the people of America or Europe.  One financial firm that rode the tech boom to the hilt finds itself with unacceptable losses except in a severe recession. Tiger Global Management was using tens of billions of dollars from pensions, endowments and rich clients riding on some of Silicon Valley's hottest stocks.  With the plunge in tech stock values including startups in which Tiger pushed into aggressively now facing large losses after hyper valuations, Tiger's hedge fund which managed $23 billion at the end of 2021 was down 52% in 2022. Another of its funds that managed $11 billion has lost 62%. WSJ says this wiped out two thirds of the gains Tiger has made in the tech stocks since its founding. In addition large writedowns are expected on its venture funds valued at $64 billion at the end of 2021, says WSJ.  WSJ says cheap money (money somehow diverted from infrastructure and funding manufacturing in China instead of the US now goes by the misnomer cheap money) reshaped Silicon Valley in the last decade, as pension funds, rich investors and celebrities turned to well connected money managers such as Tiger to put money in tech stocks and startups. This WSJ report says compared to Sequoia Capital and an earlier generation of venture companies Tiger Global is simply not interested in management of companies it invests in, taking a broad brush approach, using Bain Capital for research, and trying to haul in a large load of fish like trawlers at sea hoping for some companies to make big gains. Many pension funds such as Calpers California's public pension fund invest in Tiger with a $400 million investment. WSJ also reports that Tiger Global's venture funds do not reflect the realities of the tech business as venture stocks will reflect the drop over 2022 and 2023, including its ByteDance Chinese tech investment which will need larger writedowns. Tiger has also not hesitated to get into cryptocurrency which has loss of about $1.5 trillion dollars. It is of interest to note that Julian Robertson, hedge fund manager of the 2000 period (when Clinton-Bush were US presidents) who ran Tiger Management provided the impetus for Mr. Coleman, then 25 years old, for the start of Tiger Global. Julian Robertson closed his fund in 2000 during the dot com bust. Coleman hired a Blackstone analyst and started on the next cycle of tech with social media platform Facebook now Meta, followed by China's JD.com as investments in a new China boom were started. The end result is that during a period of Middle East wars under Bush and Obama, and building dependence on Russian oil and gas supplies under Schroeder and Merkel, China was the gainer as the US and EU lost much of its manufacturing and technology to China. During this period US and Europe neglected investment in infrastructure that would benefit the people of America in ease of living and quality of life. Just as money was wasted in wars much of the tech investment was wasted. The companies that added value over time were started long before and relied on sales growth and new products that revolutionized their field such as Apple with smartphones that started well before the nineteen eighties, Amazon with logistics and its own style of management, Microsoft from an even earlier era. Tech monopolies Facebook, Google, and others would not be missed much in terms of real progress for the people of America. The cost is many decades of ceding manufacturing and technology advantage to China by US and the EU led by Germany. China 2030 and the war in Ukraine with China's support have shown how fragile the foundations have been with weak political leadership and a finance sector running backwards in terms of America's and Europe's strengths in new infrastructure, better healthcare, services and education for the people of America and Europe. Leaving it to the Biden administration and a new coalition of Greens and Scholz in Germany to begin the task of rebuilding America and Europe on strong foundations, including the dignity of the workers and families, that makes who we are and what we believe in, and why the free world believes in us. ...

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A health care practitioner says the real problem is the high cost of medical care in the U.S. when compared to other countries. She points out that the Obama bill in 2008 did not take effective steps to bring down the cost of health care before enacting legislation to cover the uninsured, leading to higher premiums for the middle class. The link between healthcare and profits is seen as the main problem. 

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U.S. Senator Ben Sasse suggests an alternative approach of simply repealing the Affordable Care Act called Obamacare and replacing it at a later date. This is endorsed by president Trump. This is the new Republican strategy in July 2017. Forty nine senators voted in favor of this repeal in 2015, when president Obama vetoed this legislation. Two more senators are expected to support repeal according to Ben Sasse.