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The failure of private long term care insurance in the US and the need for a government subsidized and public program that requires people to carry long term care as in Netherlands and Singapore. Only about 3-4% of people over 51 have long term care insurance, leaving 95% of the population dependent on what Medicare and their savings can provide. The industry is unprofitable making at most $1 billion in one year after losses in three of the last four years when claims for 345,000 persons cost $13 billion.

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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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Care home care or nursing home in Germany goes from $1700 a month in 2018 to $3760 in 2025 doubling in 7 years. Most of it is from increase in nurses pay and training that has gonu up after years of stagnant pay levels.

In Germany 85% of older citizens elder care is in their own homes with help of relatives and outpatient care assistance is covered from a nursing care insurance fund that pays $330 to $990 a month depending on level of care required. The average pension is $1100 a month.

Statutory long term care insurance is part of German Social Security System with long term care insurance compulsory paid for by employers and employees and 3.6% of pay income going to contributions for this long term care.

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Steep rate increases hit retirees holding long term care policies. About 7.3 million retirees hold such policies.This means that either retirees pay these steep price increases or simply are forced to turn away from the policies. A safety net has now turned into something else. Sales of such policies have dropped from 750,000 in 2002 to 100,000 in 2016, and even fewer in 2017, according to the American Association for Long term Care Insurance.

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How financing for ambitious infrastructure and Atman Nirbhar Bharat (self-reliant economy) development is being financed in India is explained here. The central bank acting as debt manager for the government of India is pushing government securities to trade in lots of 5 crores or more, seven crores being about 1 million dollars. This is now being traded among commercial entities. These are essentially 3 month, 6 month, and 12 month treasury bills, and long term debt instruments for the government that run to maturities of 5 to 40 years. Retail investors are being provided opportunities to participate in a different pathway. Currently institutional investors such as banks, mutual funds, insurance companies are major participants.The government needs 1.2 million crores or $175 billion from the financial markets to fund its ambitious capital expenditures for 2021 financial year. To do this it turns to financing such as government securities. Higher demand for capital leads to higher interest rates. The RBI and the government want to keep interest rates down and one way its to broaden the base of investors for government securities which it is now doing. ...

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President Xi Jinping to introduce regulation into what was once an essentially unregulated economy, including a housing sector with financial risks built on ever increasing leverage, are expected to slow the economy to 6-7% growth rate. This is seen as acceptable to address the other goals president Xi sees as essential for the long term future of China. China urban is what most people in the US and Europe see. This is only 60% of China. The other 40% is stuck with lower incomes at about a third of urban areas and with few opportunities. Within urban areas there are the people with moderate incomes who are spooked at housing prices and living in small flats, and now with the pandemic there are many more who are unemployed as China lacks an unemployment insurance system like the US. This and Xi's close connections to farmers in Hebei, and other provinces where he has spent time as party secretary, mean he will now give all of China's people an even chance for a better life. Just as in the US with president Biden, president Xi is tackling social and economic problems left after decades of tech driven expansion aggravated income inequality and poverty. ...

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On the negative side Japan has public debt that is about twice the size if its $5 trillion economy. In the USA government debt is up to 98% of GDP.On the positive side only 10% of it is owed to foreigners compared to 46% of it for the USA. Japan is also rich in personal savings and assets. Over half of government bonds are held by the public sector and the rest are with long term investors like banks and pension funds and insurance companies. So any sudden sell off of bonds is very unlikely.

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Sheila Bair, chairwoman of the the FDIC, says the banking industry is showing "continuing signs of improvement, and the process of repairing bank balance sheets is well along, but not yet complete." The bank failures are easing and the FDIC insurance fund which had a negative balance of $7.4 billion at the end of 2010, now has a negative balance of $1 billion. It should turn positive by July 2011 when Bair's five year term ends.

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Hong Kong's new chief executive, Leung Chun-ying, is intervewed by the WSJ's Te-Ping Chen, Jeffrey Ng, and Robert Thomson. He was elected by 1200 business and political leaders in 2012. The term ends in 2017, by which time China says it will hold direct elections with universal suffrage in Hong Kong. Leung plans pro-growth policies and says Hong Kong's growth rate of about 4% for the last two decades lags too far behind Singapore's over 6% growth rate. No action is planned to reduce property prices by providing new land supply. He sees more room for growth in maritime insurance and ship financing services to complement Hong Kong's development as a global shipping center, citing London as an example. To improve the problem of cramped housing space and small apartments he is looking at ways to build new towns in the New Territories, which are on the border with mainland China. Leung will not change Hong Kong's flat tax structure, and is not going to follow Singapore's example in granting tax holidays. Growth in China will be about 7% in 2012, and future growth will depend on how fast China shifts from export led growth to domestic consumption....

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One in six dollars generated by the U.S. economy goes to pay for health care, almost twice the average for rich countries. It hurts America in many ways; by being a burden on the taxpayer when it comes to Medicare and Medicaid paying for the poor and the elderly, on companies being one reason GM went bankrupt, it eats up federal and state budgets, rising costs make any form of future coverage for all unsustainable, and it robs other priorities such as infrastructure building and other national scale investments. The Economist says that if it had to design a system from scratch, it would go for a system based mostly around publicly funded health care. For the uninsured the solution of an employer mandate is now well accepted, so this is not an issue. What is an issue is how to make the new system affordable? Here the Economist says that whether in stages or in one move, the tax deductability of employer paid health insurance, which is costing the U.S. government $250 billion ayear, has to go. It is necessary to remove this deduction, and its something all interests involved will have to swallow, as other savings are smaller and will not be adequate. The deductability of insurance makes the true cost of insurance transparent, so it supports gold plated insurance. This does not make cost control the pressing priority it needs to be. So the deducatability of employer paid health insurance hurts both ways. The other necessary action is in the area of moving out of the current culture where most doctors work on a fee-for-service basis, where the more tests they prescribe or procedures they perform the greater their incomes. This acts as a perverse incentive, and has aruinous effect in mushrooming health care costs in America. Cutting back on unnecessary tests and procedures, and prescriptions , would save 10% to 30% of health costs says the Economist. And it says this has been proven with the Mayo Clinic in Minnesota and Kaiser Permanente in California showing that cutting back doesn't hurt care and outcomes., so much so that cutting back would occur along with improved outcomes. But Americans with employer paid insurance just take things for granted as its not much out of pocket expense for them. THis creates the lack of a force for controlling costs even as employers are shouldering abigger and bigger burden, and the employee who thinks he is doing fine actually is seeing more of his salary dollars going to pay for his health insurance. In a way the consumers of health care are stuck with the perception that they are not somehow paying for these mushrooming costs and too manytests, procedures and prescriptions. This perception leads them a false sense of comfort with the system they are in, and a fear of something new fanned by the medical lobbies, that any change will impact users negatively. This makes the whole discussion on health care or the process of finding solutions to become an exericize in which terms like "rationing" and "choice" play a distorting role. ...

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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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Fears of nervous investors is now touching the bond markets. AIG's insurance subsidiaries traded their bonds at prices ranging from 38 cents on the dollar to around 81 cents, from more than 50 cents on the dollar a month ago, according to MarketAxess. Investors are worried that future restructurings will cause cash generated by AIG's units to go to the government before its bondholders, as the government has already chalked up a huge bill of $177 billion for AIG. Long term bonds of triple rated General Electric Company, which with GE Capital is the largest US corporate debt issuer, dropped last week to 63 cents on the dollar. Again investors are worried that they may not get all their money back. And again GE's CFO Sherin had to reassure investors that GE's capital position was strong. The bonds of Citigroup are trading at 70 cents on the dollar. Sales of blocks of securities called "bid lists" are not a good sign, as big groups of sales are an indication investors are desperate to unload investments quickly. Bonds issued by Goldman Sachs and General Electric without the government's backing have dropped to 96 cents on the dollar and 73 cents on the dollar, respectively in the last few days. Their government backed debt trades at close to full value or 100 cents on the dollar. ...

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All the extreme rhetoric on how Project 2025 is going to be adopted under a DJT administration has led to unease that there will be deterioration in the government and society.  Yet it simply may not work that way.   A second objective look at Project 2025 and how it's value to Republicans will be carefully evaluated piece by piece by DJT is needed. Keeping in mind 2026 House and Senate elections, winning broad support for the traditional Republican conservative line of thinking, and maintaining the support of all Republicans in the business, government, media and other sectors.  1. Replacing federal employees with party loyalists. This happens at the top of every agency of the government for every government in the US and Europe after an election for the last century. At today's unemployment level of 4 percent, adult males actually 3.9% and adult females 3.6%, and considering the higher salaries paid in the private sector, the tenuous nature of joining as a party loyalist as the national mood can shift at any time and things change again in 2027; where was the federal government going to find employees to be replaced at mid and lower levels? There is also the situation seen in 1928 when a Republican Hoover victory made Democrat NY Governor Al Smith compel a reluctant Franklin Roosevelt, who was just recovering from polio, to run for NY Governor. By 1931 over 3 years Franklin Roosevelt and Columbia University's Frances Perkins tested programs to stabilize employment in the US, introduce unemployment insurance as a new concept, and a 40 hour week also new, in the entire northeastern + midwestern states, all governors working together. By 1931 in just 3 years Franklin Roosevelt was on the clear path to sweeping victory in 1932 with a tested program to stabilize employment. 2.  The No. 1 goal is to restore the traditional family. It is clear in 2024 that the vast majority of Americans, whites, women as well as men, of all age groups, whites as well as Latinos and Asians, blacks, see that things like transgender "have somehow gone too far." 3. Cultural Literacy is needed for any nation to long survive. This is not even on any platform. Yet knowledge about America's history of settlement of the continent -correcting for treatment of American Indians, blacks, Chinese, Japanese without pointless race controversies- is being rapidly lost, and with it an understanding of America's civic institutions and Constitution, its founders and presidents, and evolution of the nation over the 20th century with the Industrial Revolution. The very terminology that has defined public knowledge about these United States is fast disappearing. It is a cause for unease in the minds of people in rural and urban, conservative and other parts of the political spectrum alike of what will happen to America as this is lost. 4. On immigration  a consensus was reached by president Biden that migrant flow was mishandled and the Lankford legislation offered by Republican leaders accepted by both parties to stop the flow. During his first term president Eisenhower conducted a program of returning illegal migrants to their home countries, Germany is doing this now and the UK's Labor party has made it No. 1 priority to stop migrant smuggling. 5. An effort to increase oil and gas production. This will help bring down the cost of living by reducing energy costs in the US and also helping Europe to do the same. Biden had already accepted the idea of the temporary need to do this to ease cost of living burden on the people of this Nation. The economic cost of wind and solar, are ultimate drivers for expanding renewable energy as major form of climate change action. In the first term of DJT 2016-2020 the lower cost of natural gas made it economical to switch from oil to gas. In the Biden term 2020-2024 all the effort to increase EV's on the road ran into the problem of lack of charging stations. It is possible that spread of charging stations could reverse this in the second term of DJT. It is the private sector and also the local governments that play a big part, climate change action will continue, and new R&D breakthroughs will happen to jump start it again.    ...

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Upward mobility in China was weak and income growth for average workers sluggish during the years before the coronavirus outbreak. In this sense China is similar to the U.S. and Europe where upward mobility gains after the second world war were lost in the last 30 years partly from the loss of manufacturing to China. It is much worse now as the effects of the coronavirus lead to drops of as much as a third in income for ordinary workers. Lower income workers, the vast majority of Chinese numbering hundreds of millions now suffer from lost work or diminished wages. Small businesses cannot afford to pay the salaries paid before and as workers dip into savings or increase borrowing the retail spending is taking a hit. As a result economists see a vicious cycle of lower spending and lower incomes for the hundreds of millions of ordinary workers in construction and smaller businesses. Some small businesses could just close down because of weak demand affecting the economy over the long term. Before the coronavirus China went over three decades from being a Communist country with relatively equal distribution of wealth but lack of growth and technological development to a capitalist country with the structure of state control of the economy from the Communist period. The result is that 1% of the people control 33% of the wealth and the bottom 25% having 1% of the wealth, according to a 2015 Peking University study. China's president Xi Jinping, head of the Communist party, tried to reverse some of these trends by attacking corruption and making changes that began the task of reversing decades of unequal distribution of wealth under state sponsored capitalist growth. Investments were made in rural medical care, infrastructure and basic services. This did not have much impact because much of the pattern of growth over three decades continues including the housing bubble.  With coronavirus the trend is set for even more unequal distribution of wealth as many workers at the bottom half of the population in incomes either lose work, or see drop in incomes as businesses that hire them struggle from shoe factories to other retail business. Reports of informal economy and street markets in Chengdu in western China and bringing this part of the economy back by the state are effort to get people work in other ways. Researchers estimate that China's bottom 60% of household in incomes lost about $200 billion in income in the first half of 2020. In May premier Li Keqiang said 600 million people in China earn only about $140 a month. Many who lost income or jobs do not have support from the government as China lacks a program of comprehensive unemployment insurance as in Europe and the U.S. to help people get over bad times. 300 million migrant workers are particularly vulnerable to loss of income and dipping into savings.   ...

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Some ideas from Robert Shiller of Yale University who has widely written about bubbles including the stock bubbles and has jointly developed the Shiller-Case index of housing prices. Shiller suggests creating futures contracts tied to home prices. And the thinking goes once there is enough trqding in these futrues contracts people can sell the housing market short-that is bet on afall in house prices- so that there is a restraining effect on housing bubbles developing. But the reviewer thinks that this is debatable because its possible to sell stocks short and yet we have stock market bubbles. Shillers other suggestion is for developing new types of insurance to protect people from a fall in house prices or from a longterm loss of income as a result of jobs becoming obsolete, but its not clear who would pay for this insurance and its cost. Another suggestion is for the government to to give subsidies or tax credits for ordinary people to get unbiased financial advice. This could be a useful suggestion if there are credible and honest sources of such advice and they are identified and made widely available to the general public by the government. A related suggestion is the development of a supplement to the consumer price index that is based on a realistic basket of goods and services that people use that gives people a realistic idea of what is happening so that they do not assume that houses are always a good long term investment and can separate inflation. And Shiller suggests a standard mortgage contract be developed so that people who cannot understand the fine print like most of us especially when its put in by lawyers for mortgage companies can turn to htis contract. This is an excellent suggestion but one wonders why something so obvious has been not already widely available as an alternative to those who cannot figure out all the machinations behind all that small print. The book is titled SubPrime Solution and one wonders whether much more than this is needed to control all the fog and euphoria about housing prices, and all the incentives and pressure in hard selling tactics of most of the large mortgage companies, and all the ethical violations of credit ratings companies who rated mortgage securities and ethical violations of mortgage companies....

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Total public and private spending on health care in the U.S. will increase by 6.1% in 2014 compared to 2014 in a revised Commerce Department forecast. The total spending will reach $4.1 trillion in 2014 from $3.9 trillion in 2013. Some of the lower rise in spending than the earlier 7.4% forecast will come from 28 states opting out of Medicaid expansion under the health care overhaul because of a June 2012 Supreme Court ruling. Employers are trying to reduce costs and the public is reducing spending because of the recession. Less generous health plans mean users are paying more out of their own pocket, paying more attention to prices and even postponing care. Growth in health care costs is a about 3.9% a year since 2009 following the recession. The costs increase in 2015 by 5.8%, in 2018 by 5.9% and 2022 by 6.5%, according to U.S. government forecasts, because of enrollment in Medicare for baby boomers. This is still higher than the inflation rate of below 2%.

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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 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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Zhou Xiaochuan, is head of the People's Bank of China since 2002. For a long time Zhou has tried to convince party leaders in China to make financial sector changes. The new leadership of Jinping-Li Keqiang has now adopted most of the road map and priorities drawn up by Xiaochuan. The first is bank deposit insurance, which would especially protect small depositors and provide a basis for new private banks to compete with large state owned banks, creating competition in the financial sector. By supporting creation of privately owned banks impetus could be given to loans to the private sector to rebalance the economy away from state owned banks and state owned enterprises. This is a key goal in the road map drawn up by the think tank Development Research Center (DRC) which has the backing of premier Li Keqiang. Competition from new private banks would let banks compete to offer higher rates to depositors, another goal. In a September article for the Communist Party Seeking Truth magazine, Zhou pointed out the pressing need for " supporting private capital to set up private banks and guide them to position themselves in serving small and micro companies." These new companies especially in tech and information technology fields can be the new drivers for growth in the future as the burst of infrastructure building generated growth slows down. The one area Zhou faces resistance is his idea of opening up China to foreign capital inflows and outflows. Here critics,including younger economists, say this protected China in the Asian financial markets crisis of 1997, and would protect China in the event it faces outflows of the type that are happening in India in 2013 after the U.S. Fed's plan to withdraw from its quantitative easing. Xiaochuan sees the flow of foreign capital as another way for capital to flow to new private companies and balance away from the state owned enterprises, and for China's savers to be able to obtain more attractive returns. Zhou says his plan would include the option for China to reintroduce capial controls in a crisis. As China's debt to GDP ratio is set on a trajectory to approach the levels reached in Japan before its banking crisis there is greater awareness from party leaders about the need for prudence. Xiaochuan has worked with party leader Jinping's key economic advisor Liu He for years, and has the support of He and Jinping for introducing deposit insurance as a top priority. President Jinping and Premier Li Keqiang see the need for Xiaochuan's experience and foresight "as a talent who can be counted on," as the sense of importance of changing the economic structure has deepened in 2013. Mandatory retirement for Xiaochuan at 65 was set aside to give him a third five year term, and his road map long ignored by former premier Wen Biao, is now at the top of China's agenda. ...

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Questions about the true cost of the Obama health care legislation and the assumption that the legislation cuts the deficit by billions of dollars. This WSJ editorial says one has to look at this closely, and not merely look at CBO projections, which may be based in a certain context and not reflect the true costs, especially because many accounting gimmicks and use of numbers to present a particular picture is taking place. The information this editorial cites is that: it uses 10 years of taxes to fund six years of subsidies, Social Security and Medicare revenues are double-counted to the tune of $398 billion, a new program funding long-tem care frontloads taxes but backloads spending, and the assumption of an automatic 25% cut to physician payments that Congress is unwilling to authorize. Rep. Rand Paul has tried to present an alternative view which needs to be studied just as closely, because of the enormous impact of a jump in spending at a time when the public finances are fragile. WSJ also cites the work of Richard Foster, the chief Medicare actuary, as an alternate perspective of how things could turn out, Doug Holtz-Eakin, and Eugene Steuerle. It calls for common sense in evaluating programs, entitlements, defense or other government spending. They not only cost money, but costs escalate over time as history has shown over decades, till they eventually are discovered to be not affordable unless the middle class is willing to dig deeper into its finances to pay for them. Alternate perspectives from a range of informed opinion, Howard Dean, Martin Feldstein, and the head of Harvard's Medical School show that the issue needs to be looked at closely and carefully and cannot be something in which CBO numbers can be trusted to tell the whole story. Especially when common sense, history, and informed opinion across a spectrum of thought advises caution, and fragile public finances also suggest caution. Howard Dean, former Governor of Vermont, says the health care bill is not real reform, and may do more harm than good. He says in a Washington Post article, December 17, 2009, the Obama health care bill does not insert competition into insurance markets, does not significantly reduce costs, and does not improve the delivery and use of health services. It was he says done with a political calculus and crafted for votes not real reform. Jeffrey S. Flier, Dean of the Harvard Medical School, gave the Obama health reform bill an "F" grade, saying in a Nov 18, 2009, WSJ article, that it was disingenuous to call this reform, Congress and the White House were simply deceiving the public. He said the bill will accelerate US health care spending, postpone most of the major health care problems, expecially the ones that drive cost, including the "fee for service" system and delivery of health care. He says in his discussions with economists and other health care leaders the opinion was unanimous that the bill will accelerate health care spending. He cites Massachusetts as an example, where access to care was expanded under the same dysfunctional system, and spending went up, and it doesn't work. Feldstein, who in early 2008 suggested proactive solutions to the mortgage debt crisis which were never adopted, says that the Obama health care law means higher taxes in the long run to pay for the $1 trillion cost of health care for the uninsured group over 10 years. Feldstein says that the Obama plan is to cut Medicare to cut spending, and will reduce the amount of medical services, as reduced spending comes from fewer services, not reducing payments to providers. And he asks if the cost reductions are weighted too heavily towards reduced services and not reduced payments to providers ,would this result in large cuts to services to affect the quality of healthcare for the 85% of the American people who are accustomed to a different pattern of healthcare. ...