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My Take on Healthcare Reform

Posted by: Michael Mandel on August 04

Imagine that you are heading down a path, and there’s a brick wall in front of you—10 feet tall by 10 feet wide. The only way you can get to the path on the other side of the wall—your intended destination—is by going sideways, in a completely different direction.


That sideways move is the Obama healthcare plan. It’s an essential step that doesn’t appear to move you towards your eventual destination.

See, U.S. healthcare actually suffers from two distinct problems.

1. Too many people are uncovered or scared of being uncovered.
2. It costs too much.

The Obama plan does a good job of addressing #1, the coverage problem, but it pushes off #2, the cost problem, to the future. In fact, it may even make problem #2 worse in the short-run.

Adding on more costs may feel like we are going in the wrong direction, but this may in fact be the right strategy in the medium-run. The reason? Trying to solve problem #2, the cost problem, is impossible as long as problem #1, the uncovered problem, exists. When you try to squeeze costs, the easiest response is to drop people from coverage. For example, paying doctors and hospitals per patient, rather than per procedure, gives them an incentive to avoid the sickest patients. Similarly, if you encourage companies to cut costs, the easiest way is to reduce coverage, either in scope or who gets itt.

On the other hand, once the great majority of people are covered, it may become politically and economically easier to get a real grip on healthcare costs. The step to the side makes it eventually easier to go forward.

Caveat: It may not be a Democratic administration that makes the step forward. Politically speaking, it will be easier for the Democrats to expand coverage, and easier for the Republicans to reduce costs. But that’s down the road.

Added 8/5
I see now that Mickey Kaus makes the same point:

First you give everyone security. Then many of the changes necessary to control costs are that much easier to make. They will be less threatening, for one. And even when they are still threatening—as some of the treatment-defunding plans of the Orszaggers arguably are—people will understand that the changes are needed to preserve their benefits, not to pay for extending insurance to someone else.

The two-step approach doesn’t necessarily mean abandoning cost controls, in other words. It might be the only way to actually achieve reasonable controls (though put me down as doubting that the cost curve can or should actually be bent very much).

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Reader Comments

Tim Brynteson

August 4, 2009 12:31 PM

The republicans of 20 years ago might have been able to cut costs, but now they are the chief panderers to corporate America (insurers, hospitals, doctors, drug makers). They will never cut costs. The democrats need to take it on now. We will hear "rationing" and all sorts of horror stories, but it is the only way to truly began cutting costs. We need leaders with courage.


August 4, 2009 12:44 PM

There is broad agreement that reforming our healthcare system is important- but when did “Healthcare Reform” become synonymous with socialized medicine, and why is the conversation focusing on who pays, rather than what is paid? Whether the Insurance Companies, Government, or individuals pay Healthcare costs, ultimately the costs are borne by the taxpayers through higher premiums, lower wages, taxes, or simply out of pocket expense.

Cost saving suggestions might include:

1. Encourage retail walk-in Healthcare Clinics, where at modest cost, trained Healthcare Professionals (ex. RNs) could treat common ailments, recommend over the counter remedies (and limited prescription drugs) and triage more serious ailments.

2. Allow Credit Unions and/or other (Federally Insured) financial institutions to offer Healthcare Savings accounts as a service- rather than an employer-based model. These same institutions could offer Group insurance policies at a lower cost than individual policies. These might take the form of catastrophic coverage policies to coordinate with the Healthcare Savings Account reimbursements.

3. Consider funding the education of more healthcare professionals- presumably driving down the cost of routine care- and perhaps offer a work-study program or internship to offset/repay that tuition.

4. Tort reform. Plaintiffs are certainly due the compensatory damages they are awarded, but where is it written that punitive damages must be awarded to the plaintiffs and their lawyers? Punitive damages are a necessary deterrent, but if they were instead awarded to Charitable Organizations, the incentive to file spurious lawsuits would be diminished.

5. The Pharmaceutical companies need to generate profits to stay in business and continue to provide and develop medicines- but why are they allowed to charge more for those medicines in the United States than elsewhere in the world? A more universal pricing policy would reduce costs for U.S. Citizens as well as the U.S. Government.

6. Rather than legislating Healthcare, the Government could draft, publish and support “model” healthcare insurance plans, which then could become a standard against which all privately offered policies could be measured. It might be reasonable to offer several levels of policies:

-A basic plan that might cover emergency care, along with diagnostic and preventative care
-An enhanced program with generic prescription drug coverage, and co pays/subsidies for name brand drugs
-A high level policy with broad coverage, which of course would be called the “Congressional Plan”

Once the model or standards are in place, it would become much easier to comparison shop the policies as all plans that are in compliance with the model offer (at least) the same basic coverage. It might even be easier to administer the plans, as specific coverage would be common to all compliant plans. No Insurance Company, or any other entity, would be obliged to offer plans designed to be in compliance- but perhaps Healthcare Insurance Plans that are in compliance with the model AND offered by credible, responsible institutions could offer the plans nationally- by private companies.

7. Excessive and possibly unnecessary testing procedures are often mentioned as one of the components of spiraling healthcare costs. Healthcare professionals explain that performing these tests is necessary to protect themselves from possible litigation. It may also be that many of these same Healthcare Professionals have financial interests in the facilities that perform these tests, providing an incentive to proscribe testing procedures that may not be necessary in terms of diagnosis. Greater scrutiny and transparency is required.
The logical question is if the purpose and goal of Healthcare Reform is to reduce the cost of Healthcare, why does adopting such a plan have significant costs associated with it? The plans currently under discussion are expected to cost taxpayers upwards of one trillion dollars over the next ten years- how is this a cost savings?


August 4, 2009 01:47 PM

I think you are right. Opponents often argue this would entrench special interests making it impossible to cut costs, yet no other country on earth has that problem. The real problem is special interests now who must be bribed to not oppose a program. We already spend too much on healthcare for what it can do and we would be better taxing it than subsidizing it, but without change we will spend ever more for less.


August 4, 2009 02:00 PM

Your whole point is based upon a false premise. You can solve the coverage problem without creating a government managed insurance offering, something central to the Obama plan.

Put regulations in place for insurers so they can't cherry pick or discriminate, and I suspect a majority of folks would be comfortable with the reform.

There is no more reason to create a government insurance option than there is a need for the Federal Rerserve to own all the banks.

Just create a health insurance marketplace that consumers can trust. A tall order, to be sure, but that's the simple key to it all.

Damian Palmares

August 4, 2009 02:11 PM

If the Cash for Clunkers program is any indication of how the Democratic administration at this time is projecting the cost of health care, we may be in trouble if it is pushed through. The original C for C plan was supposed to have enough funding to last through November. It was drained and underfunded within one week's time. Just something to think about.


August 4, 2009 03:01 PM

You can choose to walk around the wall, as the Obama plan would, or you can choose to talk through the wall. National Health Insurance will obviously help improve coverage but will have a vanishingly small impact on costs unless quality is at least partially sacrificed.

You still aren't addressing one of the major underlying causes to healthcare inflation: consumers do not directly purchase their healthcare (or even insurer in most cases!). There is essentially no incentive for me to purchase the generic equivalent of my medication when my copay is only $5 more for the branded version. Costs could be more easily cut if we removed the exempted status of employer-provided insurance. Similarly, coverage could be improved if the government supplied, in one form or another, catastrophic insurance; fewer people may be on supplementary health insurance, but overall healthcare coverage improves.

Reigning in costs is difficult when those making spending decisions, such as healthcare consumers, pay the bill with other people's money. I'm sure you know a few business executives who can testify to that effect.


August 4, 2009 03:41 PM

So many misconceptions ... please read, as well as watch this video by Ron Paul (MD) in order to get a good idea.


August 4, 2009 04:08 PM

Better future??

Just look to Western European countries. There is only one thing which a government induced "universal" healthcare system created:
An enormous magnet for poor people all around the globe who are drawn into the free social welfare systems and drag down the entire system for the government has to find that money somewhere else, i.e. TAXES.

There is no miraculous utopian "better future" when a system encourages less self-responsibility. History should be a lesson, but, ouch, who remembers any?

If your "better future" is less personal responsibility, less independence, more government regulation, more TAXES, less creativity, more poverty and less perspective than either go to Europe or repeat the Roman experiment.

Wealth and prosperity are not created by stealing from others, including our children. They were and always have been created by the sacrifice, discipline and frugality of our ancestors. Time for us to do our share and stop behaving like whining little children for each and every "entitlement"

an Ex-European

Cathy Arnst

August 4, 2009 04:38 PM

Mike - There is a precedent for tackling coverage before costs: Massachusetts. The state passed a law instituting universal coverage in 2006, but punted on the cost issue because state legislators realized it would be too hard to do both (and this was an initiative started by a Republican governor). Now, the state has the lowest uninsured rate in the nation, under 3%, but is facing a financial crisis because of the cost. Which in turn forces the state to make the tough choices--e.g. scrapping the fee for service system--that there was little political stomach for three years ago. Be interesting to see if national health reform follows the same route. (for more on Massachusetts, read: )


August 4, 2009 05:29 PM

I don't buy that we *have* to attack the problem of health insurance coverage before the problem of health care cost. That's just a matter of political priorities: attacking costs first gets you fired in politics.

Trying to improve information costs on health procedures, breaking the AMA monopoly, realigning the FDA around improving information on what's available rather than acting as the nation's sole food and drug quality filter, and basically trying to make a free market on health care would improve costs and quality dramatically over time. But health insurance is the face of health care, and therefore a much easier political target.

On that front, doesn't a solid high-deductible plan (that can't be denied) plus HSA-type vehicles (or whatever people want to buy on the free market) make much better sense? People with severe and chronic issues will get the short end of the stick to some extent. Unfortunately, I don't know there's much we can do about that. At least they should be better off than now in that such issues shouldn't cause automatic bankruptcy.


August 4, 2009 07:53 PM

I'll listen to the "government can solve it" as soon as somebody shows me a government run entity that has ever been concerned with costs, was as efficient as the free market or isn't driven by the political winds of the day.


August 5, 2009 12:32 PM

I agree with westernfan completely.Why hasn't the Obama administration proposed this kind of comprehensive plan,yet simple in concept and without huge government involvement and cost?


August 5, 2009 05:26 PM

This totally misses the point that Dems are still inserting the legal tools to win in the end. It may not be as direct and as fast as first rammed into the pipeline, but the legal web is still cast to force the outcome over time. How about reading and documenting facts about those provisions?


August 6, 2009 11:51 AM

One of biggest farces is choice in healthcare. As most healthcare is employer provided, few have much of any say in it. It is too bad the public option is being denied to these people which would be the only real choice they have. There are powerful interests preventing any actual competition and cost cutting in healthcare.

Joe Cushing

August 6, 2009 01:12 PM

I think the Obama plan is more than 90 degrees off--more like 175 degrees off from where we should be going. The problem with health care is government involvement. How is making more government involvement going to solve it? We need the government to pull back from health care.

Brandon W

August 6, 2009 01:43 PM

There are three big elephants in the room that no one has the testicular fortitude to deal with. Deal with them and the costs of health care will drop precipitously.

First, Americans are in horrible health. Some of this comes from insufficient exercise, but most of it comes from a food system that is economically rewarded to produce food of lower nutrient-density and higher sugar content (including refined carbohydrates). In 1830 Americans ate 15 lbs of sugar per year. We now eat over 150 lbs of sugar per year. We have more calories than we need, but Americans are literally starving of proper nutrients. Rates of disease have increased dramatically in the past 50 yrs, though deaths may have held steady (or even declined). More disease, but it's mediated by extensive health care and pharmaceuticals.... at a price. Start with the elimination of a system that subsidizes the growing of corn, which is processed into disasterous ingredients such as High Fructose Corn Syrup as well as used to feed cattle and chickens for which the corn is not a natural food and not producing healthy meat for our food system. (As a side note, foods with HFCS were recently discovered to contain high levels of the toxic element mercury, due to the process used on corn to create the HFCS). Make the destruction of whole grains for use in the food system illegal (i.e. no more refined carbohydrates). Stop allowing - or even encouraging - food producers to produce foods that are destroying our health.

Second, health care costs have increased because of the aging of the Baby Boomers. Insurance intends to "level" the costs, spreading it among the younger, healthier individuals in society. But when the overall age of the population increases, the overall average cost will rise. This is exacerbated by the fact that the generations behind the Baby Boomers are smaller, and are thus paying less into the system. Baby Boomers are the wealthiest group; let them pay their fair share of the costs they incur to the system. Especially for life-extending treatments and drugs. If Americans don't inherently have a "right" to health care, then Baby Boomers don't inherently have a right to extended lives at the expense of Gen X and Y. If they want the drug that will let them live another 6 months, they're going to pay for it, cash, out of pocket.

Third, the American Medical Association and other medical lobbies have pushed the government into severe restriction on the provision of health care, thus limiting supply. Most basic health care could be provided by degreed nurses and physician assistants. Naturopathic Doctors should be allowed to practice as regular physicians; because if Americans are allowed to have free choice in how their health is cared for, they should be allowed the freedom to choose Naturopathic care. Break the AMA lobby's grip and open up health care practice to providers who are perfectly trained and capable of doing so. Increase the supply.

These are the biggest three reasons our health care system is so expensive, yet our health and life spans are among the lowest of any "first world" country. Does anyone in Washington, D.C. have the guts to take on the agriculture industry, the Baby Boomers "democratic" demands, and the AMA? Probably not. Until the the cause of the disease is removed, the patient will only get sicker.


August 6, 2009 02:26 PM

I Hadn't read WesternFan's entire comment beforehand, but he is 100% correct and much more detailed than I. For me, the most frustrating part of this is that the kind of reforms WesternFan outlined do not have clear ideological enemies (i.e. are Bipartisan!). Unfortunately the issues-oriented media is all to eager to encourage inferior solutions tied to vague promises.


August 6, 2009 02:56 PM

Nice post, BrandonW.

I'm sensing a lot of general agreement on a few themes... I wonder why commenters here are the outliers in the general debate?

Mike Reardon

August 6, 2009 06:23 PM

Employers covers 59% of employees, then State and Fed programs cover 23% of the qualifying poor and disabled.

The other 18%, 47 million employees are low income workers or uninsurable individuals who can’t afford health care even when it is available.

The best system would be vouchers for parity services for the low income and chronic ill to the standard market level of health service.

The issue when a health care system is in place and covers beyond employment, is job churn. Will a State care program take a Federal insured employee re-entering the States health system under State aid programs. The odds are temporary employees leaving the State system will be displaced from that State system for good.

But that offset from the States expenses may offer a selling point on fuller Federal coverage against State costs.

Another point when corporations file for bankruptcy the first cast-offs is the funding of there health care obligations. Those obligations fall to Federal programs that reduce the services the employees previous insurers carried. This is not going to be a simple extension of health insurance by market forces.

You will find the present system is collapsing on so many levels for so many employees now, that the market is not supporting as many on a standard market level of health service as is imagined. Taxing higher incomes is better than placing even greater stresses on small businesses.


August 6, 2009 06:39 PM

I am actually going to agree with Brandon W.

Americans eat the worst food in the world. America is to food what North Korea and Zimbabwe are to economics.

That being said, it is a question of PERSONAL DISCIPLINE. I don't think the government has a role in this. Prevention is a lot cheaper than cures, and one can distinctly reduce their chances of getting cancer, cardiovascular disease, diabetes, or Alzheimer's, with proper diet and exercise.

Americans know absolutely nothing about a healthy diet. Unless 90% of what you are eating are fruits, vegetables, and whole grains, you are eating a bad diet. Sometimes I wonder if Americans know what people ate before the 20th century.

Brandon W

August 7, 2009 10:47 AM

Mark this day. Kartik and I agreed on something. :-)

However, I do think government has a role in this that even Kartik could agree with: Stop subsidizing the agricultural industry, especially to grow corn. This market distortion is a big part of why HFCS exists, and why animals are fed an unnatural diet of corn-feed which contributes to low-quality meat. Thus the government CAN play a role by not shifting tax dollars to subsidize a food system that creates poor health. The US spends about $3 billion/yr to subsidize a product that causes hundreds of billions of dollars worth of health care costs. Send those tax dollars off to pay off the national debt or improve the schools. The government can also play a role by eliminating ridiculously unnecessary guidelines for health care provision (which only exist thanks to the AMA lobby, et al) so a wider range of trained professionals can provide care.

I just wanted to clarify that I wasn't calling for government intervention as much as I was calling for the government to QUIT intervening. On that I think Kartik and I have significant common ground.

Mike Mandel

August 7, 2009 11:39 AM

CompEng writes:

>I wonder why commenters here are the outliers in the general debate?

Because there's more than one debate going on about more than one problem, and a lot of times people are talking past each other.


August 8, 2009 04:13 AM

The less government intervention, the better.

One thing about industrial lobbying is that so many lobbies are contradictory to one another.

The agricultural lobby gets a corn-growing subsidy, that causes obesity and higher health-care costs. So shouldn't the AARP lobby be opposed to that?

I wonder what is the ranking of lobby power/clout. Is it Seniors > Autos > Agriculture > Oil > Trial Lawyers > Pharmas? Or some other order?

There are clear cases where the action of one lobby hurts the interests of another powerful lobby. AMA vs. Trial Lawyers, or Oil vs. Autos, for example. Yet we don't see these interests clashing.

Karen S

August 9, 2009 06:03 PM

If "everyone" is covered by a Government Healthcare plan, who is going to treat them. We are already have a shortage of doctors and especially nurses. It's capacity issue. You can only throw so many sick people at an already strained medical system before we become like Canada, where everything is elective unless you are gushing blood. Do we really want a system that decides whether or not you are worth saving? What value does a 75 year old have over a 16 year old? Are we ready for "Big Brother" to determine our value??


August 12, 2009 09:31 PM

Karen, we DO have a system that decides whether or not people are worth saving. If you have enough money, you're worth saving; if you don't, too bad.


August 15, 2009 12:02 AM

I am more concerned that this will be paid outside of taxes if people have to pay personally and that the government will have direct access to you checking acount. It will be automatic. They cant have people sending money or not sending it, like stalling your cable bill. It will not be optional. Once they access to take money they can see inside it, and take more if they want, or rather when someone does. The government is made up of individuals who can steal your money, besides giving them power over all your cash


August 15, 2009 03:04 PM

I am Canadian, and we still have our freedoms as well as government funded health care. I would rather have our troubled system then the current system in the U.S., I can depend on getting the medical help I need, without the risk of losing my house and everything else. Everyone gets basic coverage, but if you have lots of money you can go and find other treatments, while in the U.S. You only have coverage If you have money. And for all these "joe sixpack idiots" disrupting the townhall debates, guess what - all other emergency services are already socialist (since you love throwing that term around), your police, paramedis, fire depts, are all socialist. And wow your still free! Why did you sit on your asses when the patriot act was pushed through, that is the one that eliminated personal freedoms and turned your government into a form of dictatorship. Wake up!! People need assistance.

Mike Reardon

August 16, 2009 12:10 AM

Tony August 15, 2009 03:04 PM from Canada, above:

(all other emergency services are already socialist (since you love throwing that term around), your police, paramedis, fire depts, are all socialist.)

Civics lesson, Civic Public Services for pubic safety have nothing to do controlling completive productivity. They only have there limited role for public safety.

In the US where possible contract services are replacing public services.

Prisons are on many state built and run by public companies, we even contract air services in fighting forest fires,

We employ private or public companies to augment all the basic public services. Even our military, totally financed by our taxes and directed by Congressional decree, contracts all of the creation of our military hardware to public companies. Our military, even uses public company ships to transfer US troops into military action and even food services in nations where combat is goin on have private cooks services under contract.

Of the $70 billion extensions to keep troops in Iraq most of that will be spent within the US and then shipped to the action. I never understand how anyone can see our Medical Care going to a commissar system when our military hardware companies and prisons are now listed on the stock exchanges.


August 17, 2009 09:46 AM

i am a canadian citizen and love or medicare system. seven years ago i had cancer and within a couple of months i had chemo, radation and major surgery without it costing me a penny. The only thing i had to worry about was getting well not about the cost at all. It sure was nice not having to worry about money at that trying time. So if you people want to really see how lucky we are in canada come see me. Oh one more thing HOW IS THAT CAPITALISM WORKING FOR YOU NOW!!!!!!!


August 17, 2009 09:46 AM

i am a canadian citizen and love or medicare system. seven years ago i had cancer and within a couple of months i had chemo, radation and major surgery without it costing me a penny. The only thing i had to worry about was getting well not about the cost at all. It sure was nice not having to worry about money at that trying time. So if you people want to really see how lucky we are in canada come see me. Oh one more thing HOW IS THAT CAPITALISM WORKING FOR YOU NOW!!!!!!!

geri from ontario, canada

August 17, 2009 09:58 AM

i am a canadian citizen and we have a really good medicare system. It sure was there for me when i needed it. Seven years ago i had cancer and within a couple of months i had chemo, radiation and major surgery and it didn't cost me a penny everything i needed was covered it sure was nice to only have to worry about getting well instead of money since we are just middleclass. So if you people would like to see just how lucky we are with our healthcare just come see me. Oh one more thing HOW IS THAT CAPITALISM WORKING FOR YOU NOW!!!!!

geri from ontario, canada

August 17, 2009 09:58 AM

i am a canadian citizen and we have a really good medicare system. It sure was there for me when i needed it. Seven years ago i had cancer and within a couple of months i had chemo, radiation and major surgery and it didn't cost me a penny everything i needed was covered it sure was nice to only have to worry about getting well instead of money since we are just middleclass. So if you people would like to see just how lucky we are with our healthcare just come see me. Oh one more thing HOW IS THAT CAPITALISM WORKING FOR YOU NOW!!!!!

geri from ontario, canada

August 17, 2009 09:58 AM

i am a canadian citizen and we have a really good medicare system. It sure was there for me when i needed it. Seven years ago i had cancer and within a couple of months i had chemo, radiation and major surgery and it didn't cost me a penny everything i needed was covered it sure was nice to only have to worry about getting well instead of money since we are just middleclass. So if you people would like to see just how lucky we are with our healthcare just come see me. Oh one more thing HOW IS THAT CAPITALISM WORKING FOR YOU NOW!!!!!


August 19, 2009 09:33 PM

I like the graphical representation of present healthcare situation here but want to make some correction to it. The wall doesn’t represent stop sign. Deep hole should be there instead of the wall and here is why.
Many people continue to lose their jobs and medical coverage along with it.
1. They still have to pay their mortgage or rent.
2. Water?
3. Do they need food?
4. Car payment and gas?
5. Car insurance?
6. Credit card debt?
Now, everyone gets health care treatment when they walk into emergency room and then end up with bills above their head.
You don’t need to be a scientist to determine peoples’ priority for healthcare bills on the list above. If things will continue as they are in the healthcare arena, many people will just stop paying for it and their friends and friends of their friends will know that most people just don’t pay for it. What do you think will happen next? – That’s right, no one will pay for it …Hospitals will start letting their workers go, not being able to pay them. They are doing it now. Talk to anyone you know in healthcare.
Where does Obama go? At least not in the hole, where we would end up otherwise.
Politicians!!! Welcome to the world of macroeconomics. All your microeconomics views are about to change.

People are afraid of doctors….WOW!! –What a wonderful healthcare.

Ryan Stotler

August 21, 2009 10:22 PM

I hear a lot about health care being a privilege, especially from the privileged themselves. The reality is, everyone should have the right to live healthy and happy lives without being scared to death about getting sick. Now you will always have people that make themselves sick by smoking and drinking and other vices, but there are plenty of people who get cancer by doing nothing wrong at all. It's a genetic condition. You have people that need regular check-ups, like diabetics and they can't because the health care that is offered to them is not even second best, it's closer to some of the worst health care offered. Did you know we ranked just ahead of Slovenia on the best health care? SLOVENIA!! How many of you could even point that out on a map without a lot of searching? Probably not many of you. The fact is, the nations that are offering these programs are shown to have better health care and programs for their citizens. You'll always have some whiny millionaires complaining about substandard care, but that's because it's not the Rolls Royce, above and beyond the necessary amount approach they are used to. It's the appropriate approach. In France, they offer a much more lengthy amount of time to care for a newborn than the 12 weeks they offer in the United States. They also make a nanny service available to help those new parents out. While I am not suggesting total socialization of medicine, I think we would be better off if we offered more than what we did now and lowered the cost of the goods they give you in a hospital. $200 for one motrin? Give me a break! I know we are so frightened about hospitals shutting down and mass hysteria taking place, but come on, we have a government in place for a reason, to help us and take care of us. Not to take care of itself and it's members.

Thank you for your interest. This blog is no longer active.



Michael Mandel, BW's award-winning chief economist, provides his unique perspective on the hot economic issues of the day. From globalization to the future of work to the ups and downs of the financial markets, Mandel-named 2006 economic journalist of the year by the World Leadership Forum-offers cutting edge analysis and commentary.

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