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This report in the WSJ by Peterson and Hackman shows how the American Health Care Act proposed by Speaker Paul Ryan provides less financial support and allows premiums to go higher for seniors approaching retirement in the 50-64 year age group. Premiums are allowed to go up 5 times that of premiums of young people in the Ryan House  plan compared to 3 times in the Affordable Care Act. Subsidies in the form of tax incentives provide $2000 to younger people going up by age not income to $4000 in the Ryan House plan. By contrast someone 60 years old making $20,000 a year can get Affordable Care Act credit of $9874, and making $40,000 a credit of $6752, according to analysis by Kaiser Family Foundation. The Ryan plan makes health care costs lower for young people in an effort to bring more young people who use less services into the system to support its overall financial condition. Another feature of the Ryan Plan is that it allows only for CPI index +1% even if health care costs are rising faster. Deep cuts to Medicaid affect lower income seniors on Medicare. As a result the AARP organization representing seniors has come out in opposition to the Ryan bill. The GOP plan wants to reduce premium costs yet in the process it makes vulnerable seniors with lower incomes pay more, which is likely to hurt Republicans who won by winning a large part of the senior vote. ...

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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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Weigel of the Washington Post compares how the Affordable Care Act was passed in Congress in 2012 with the push by Speaker Ryan and the Trump administration for the American Health Care Act in 2017. Republicans he says are making the same mistake as Democrats by rushing this through Congress. There is no broad consensus on whether all Americans should be entitled to health care as in Europe and Japan for their citizens, and health care is priced in a way to make it expensive for the state to provide- until the twin problems are solved by creating a new culture in the U.S. that sees things differently, politicians will come up with their own plans based on their interests and which groups they serve.

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The Congressional Budget Office analysis of the Republican House health Care bill shows 24 million Americans would lose health insurance over 10 years. In terms of budget savings the bill saves $337 billion over 10 years. The increase in uninsured comes from the roll back of expansion of Medicaid under the House plan, the reduction of tax credits, plus the removing of income based credits replacing it with tax credits based on age. President Trump is promoting the bill saying it will reduce the premiums that have gone up since Affordable Care Act was passed and increase competition. House Speaker Ryan in promoting his plan says he is not in "some coverage beauty contest." The House Plan says Ryan, does not mandate that all be covered, but simply says coverage is in a free market giving people the option to buy insurance that they want, so that the numbers of insured would not be as many as under a mandate.

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Shear of the NYT says president Trump is taking risks of losing support from low income people who supported him in the presidential election by making aggressive cuts in programs that help low income people. In his first budget plan deep cuts to social programs and increase of 10% in defense spending of $54 billion is planned. The new health care plan of the Republicans House and Speaker Ryan is seen by the Congressional Budget Office as increasing uninsured people by 14 million. Trump has left Social Security intact, but he sees other cuts as cuts to the "administrative state' and overreach on entitlements. The budget plan is titled "America First," and shrinks foreign aid, cuts state department budget by about a third, and cuts funding to PBS, other agencies, and cuts social program spending.

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Peter Coy of Bloomberg Business Week points out that the debt ceiling and proposed deficit reductions in the range of $4 trillion really obscure the real size of the problem which is much larger. The real problems hit when the U.S. faces a larger graying population by 2020 with sharply higher per capita health care spending; and at the same time workers from this generation retire and become beneficiaries of Social Security and Medicare with fewer younger workers to support the system with tax revenues. Another problem is that older Americans are likely as a voting bloc to vote themselves benefits that will cost the younger generation, benefits that the younger generation will not be able to enjoy. Even the Paul Ryan plan with its cuts to Medicare insulated todays seniors from the sharp cuts, as it becomes political necessity for both Republicans and Democrats to shy away from touching the current beneficiaries.

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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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David Brooks of the NYT describes the approach taken by British prime minister David Cameron and his Conservative Party government to help the working class poor in Britain, and tackle the social roots of poverty. He says an American adaptation similar to this is badly needed in the Republican Party, with the candidates in the election providing solutions from an old rulebook. Only after Trump's popularity with appeals to less educated older Americans has the Republican leadership responded, with Speaker Ryan helping organize a forum on poverty under the Jack Kemp Foundation- emphasis was placed on education, work, opportunity and accountability for anti-poverty programs in the discussion moderated by Ryan and Senator Tim Scott. Less attention was paid to the other social aspects mentioned here by Brooks, and cited by Cameron when he described the inadequacy of traditional solutions from the right and left of the political spectrum. Cameron outlined the principles of his anti-poverty plans called "Life Chances Strategy," in a speech on Jan. 11, 2016, in north London, with the entrie transcript on the gov.uk website. Cameron acknowledged in the speech that social issues including single parent families, and other social problems such as long term unemployment, can make it harder for some people to use self-reliance and personal responsibility in a growing economy as a way to grasp opportunities. Cameron proposes a combination of economic, social and job growth strategies. His second term plans include 30 hours a week of free childcare for 3 and 4 year olds so both parents can work, parental maternity leave, expansion of Troubled Families Program, in addition to the introduction of National Living Wage, tax cuts, universal credit. In tackling social aspects of the problem Cameron cited the need for development in the early years of childhood, the huge importance of family, social connections and experiences, informal mentors, cultural experiences, broadenend horizons, that enable young people to acquire language skills, character and resilience. Second term projects include expanding reach of high performing schools to deprived areas, emphasis on core English, math, science, history, geography Ebacc skills, a 1 billion pound investment in the National Citizens Service by 2021, a plan to transform housing estates including rebuilding from scratch, additional 1 billion pounds to provide mental health treatment including treatment within 2 weeks in homes and communities. Throughout Cameron's "Life Chances strategy" is aimed at tackling not just the material dimensions of poverty, but also what he describes is broken in Britain- "the paucity of opportunity."...

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This Washington Post editorial says Obama and the politicians, both Democrats and Republicans, want something for nothing. The Ryan budget, Obama's health care plan, all require paying for it with higher taxes, but the mention of the word "tax" is the last word any of the politicians will say. These comments come as the U.S. Supreme Court considers the mandate that young Americans and others be forced to pay for health care along with the rest, as required by the health care mandate, with the idea of keeping costs down. The idea of getting something for nothing was also emphasized in an op-ed in the WSJ, March 29, 2012, by Mayor Bloomberg of New York City, where he called for letting the Bush tax cuts expire for all income groups, and an up or down vote in Congress on the Simpson-Bowles deficit reduction plan, as part of a two step plan.

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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 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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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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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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This Economist magazine editorial says the Republican plan for health care with its roll back of Medicaid expansion by limiting funding to states after 2020, and by scaling back subsidies especially for older Americans and not basing them on income levels, is likely to have its own problems just as the Affordable Care Act. One concern is that keeping healthy people in the market with a mandate that everyone have insurance is present but in a milder form with premiums going up by 30% in one year if they change their mind. There is concern that this may not work among insurers leading to an increase in premiums, pricing people out of the market in "a death spiral." This could lead to more people being priced out of the market as premiums rise. About 12 million people were added to Medicaid by increasing eligibility level to $16400, or 138% of poverty line- this reduced the uninsured from 16% in 2010 to 8.8% today. The Economist concludes that the Republican health care bill has its own problems, and that this bill does not clear up the problems in Obamacare by substituting Ryancare as the Republican bill is called. Peggy Noonan writing in the WSJ says this may have negative consequences for the new Republican base shift to populist support. Critics on the right like Rand Paul see even the reduced subsidies as an entitlement program, yet the Republicans can only change parts of the Affordable Care Act as they need 60 votes in the Senate where they only have a small majority.   ...

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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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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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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.