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Lots of talk about health care, why single-payer supporters don't get more love, why seniors are so selfish, and whether Chistopher Kimball is actually insane. Enjoy!


Columbia, SC: In honor of Twitter's down period, I think all responses should be made in 140 characters or less.

Ezra Klein: I am very tempted to do this. But I will not. Questions, however, should definitely be under 140 characters!

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New Haven, Conn.: Ezra, what do you make the most recent CNN poll on health care reform that showed a generational divide between those who want reform (the under-50s) and those who don't (the over-50s)? Given that the over-50s are about to benefit from government-run health care in the form of Medicare, I find their (overall) hypocrisy amusing.

Ezra Klein: America's elderly effectively live in Canada. They have single-payer health care. They have a government-run, defined benefit pension plan. And they like it. Their opposition is a funny kind of opposition: They're not worried that the government is going to take over health care. They're worried that they're going to lose their government-provided health care.

I wrote a longer post on this the other day, and I'm just going to copy my conclusion from there. Generally speaking, people who oppose health-care reform are worried we're going to end up with something like what Canada has. Not seniors. They have something like what Canada has (Canada, in fact, also calls their health insurance program "Medicare"). And they like it. They report higher rates of satisfaction with their health care than do people in employer-sponsored insurance. They're worried, rather, that they might end up with something like what the rest of America has. And having spent time in both Medicare and private health insurance, they don't want that. They don't want that at all.

This means, of course, that they oppose health-care reform in uncommonly high numbers because they're concerned about changes to their situation. But for the rest of us, it should serve as a pretty good argument for heath-care reform, and particularly for something like Medicare-for-All.

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Mexico City, Mexico: Ezra,

You've written in the past that you don't think that congress will successfully meet the challenge of climate change. But I seem to remember at the beginning of Obama's term that there was some talk of having the EPA use its authority to "impose" a cap-and-trade system on the U.S. economy. I can understand why the administration would prefer to get a bill through congress, but what if it can't, or it's too watered down to be effective? Have you heard anything about whether the EPA option remains on the table? Thanks!

Ezra Klein: The EPA option remains on the table. It is, in all reality, a problematic option, for reasons that a search of environmental blogs will turn up. The best way to think about the EPA option is less as an actual option for carbon control and more as a threat to recalcitrant businesses and the senators who listen to them. If we go the EPA route, business is really going to have a crummy time of it. The hope is that they realize that, and decide to accept a decent and transparent carbon trading scheme.

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Re: Cash For Clunkers: Ezra, I don't understand the Republican criticism (but when do I ever?) to this program, calling it a boondoggle because it already needs more money.

If my local store decides to boost sales with a special promotion and they clear the shelves of product, why is that a bad thing? Don't you think their parent company would agree to give them more resources to keep the promotion going so they could sell more stuff?

I thought the Republicans understood capitalism.

Ezra Klein: It's been confusing. There's a legitimate criticism of cash for clunkers that it doesn't do enough to force the purchase of high-mileage, environmentally friendly vehicles. But it's hard to say that a bill that was meant to kickstart car sales is failing because it has kickstarted car sales.

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Central Mass.: Ezra, why do you think Christopher Kimball (the America's Test Kitchen guy) is insane?

Anal, sure, but insane?

Ezra Klein: It's his editorials at the beginning of each issue. They read like a parody of a 1920s naturalist. I originally thought they were satire. Particularly given that they have a picture of some guy in a bow tie next to them.

Kimball isn't insane, of course. He produces an impressive product. But he's quite a strange character.

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New York, NY: Hi Ezra, Does Max Baucus know he's getting played in the Finance Committee bipartisan negotiations? Chuck Grassley and Mike Enzi are never going to sign on anything worth passing (Olympia Snowe is another matter). Does Baucus actually believe that they will, or is this all for show, a tactic, for later passing something more party line? And does Baucus have a Plan B for when this inevitably falls through?

Ezra Klein: I don't think it's that simple. Max Baucus probably isn't getting played. Grassley would like to pass something alongside him. My question is whether Baucus understands that Democrats in Congress are going to want a piece of this bill. The problem isn't that he can't come to agreement with Grassley, but that that agreement won't stick once the bill goes to committee and then to the floor. And then Baucus will lose Grassley.

Does he have a plan B? I don't know. I hope so.

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Washington, DC: You mentioned the other day in a very thoughtful post that some "rowdy protesters" get media attention, and others (like single payer advocates) do not. What do you think accounts for this discrepancy? Do you think the media is so careful not to seem elitist by criticizing working-class, old, angry whites?

Ezra Klein: Hard to say. I think that the conservative protesters map onto a conflict that the media wants to cover, while the single-payer protesters don't. To say that more clearly, the conservative protesters are a visual manifestation of something that might happen in this story: Conservatives kill health-care reform. The single-payer protesters don't really connect to a larger story, at least not as far as congressional and political reporters are concerned.

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They read like a parody of a 1920s naturalist.: I always think of it as an unfunny News from Lake Woebegone.

Ezra Klein: Well put.

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New York, NY: In your post on the anniversary of Medicare, you linked to LBJ's emotionally powerful address and said there were no McKinsey graphs in sight, implying that the most effective way to advocate for health care reform is through making it REAL, through personal stories of hardship and of concrete improvements. He made the moral urgency and tangible benefits of health care reform so real, so personal, and this direct emotional message seems essential to advocating for progressive reform. When the case for health care reform becomes too technical, it leaves the President's appeal vulnerable to emotionally powerful messages from the opposition. Why has Obama, the Democrats, and the progressive infrastructure allowed the right to monopolize the political power of emotion and personal stories? How much has this damaged the cause of reform in the public discourse? And is there time to turn that around?

Ezra Klein: I don't really know. Obama does bring up stories. But he's not very good with them, and never has been. People forget that Obama was pretty unpopular with health care types during the campaign. This was in part because his plan was the worst of the three, and in part because he was the worst at talking about health care. He was bloodless about it. It didn't really seem like his thing. It didn't seem to be what he was passionate about.

That latter judgment was, I think, wrong. he clearly does care, asnd is fighting on this. But he's not good at selling it. He's good at explaining it. But those two things are different. Obama hasn't given a definitional speech on health care, the way he has on race, or greed, or Barack Obama. He's not elevated health care into a theme or a challenge or a story in the way he did with those subjects. I don't really know why that is.

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Alexandria, Va.: What do you make of the angry elderly town hall attendees complaining about government paid health care? How many of them would give up Medicare? How many veterans would give up the VA system?

Ezra Klein: Just about none of them. Satisfaction in both the VA and the Medicare are higher than in private insurance.

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Grand Junction, Colo.: Ezra - What's a succint counter to people who continuously assert "the market will solve all" and the like, in reference to health care reform or any other ail of the day? It's mind numbing and I want friends with this "view" to think about what they're saying.

Ezra Klein: Look around.

The thing about the market is that it doesn't solve problems. It works towards efficiencies. The market's solution to the problem of "a lot of people can't afford health-care coverage" is that "a lot of people can't afford health-care coverage." That's what the market does: Given scarce resources, it apportions them according to the capacity to pay. A lot of people can't afford a Lexus. Thus, a lot of people don't have a Lexus. That's not a market failure. It's the market's solution.

The market isn't failing to solve the problem here. It's just that we don't want the market's solution. We want people to have health care. So we need to go beyond the market. It's the same as fire departments or national defense or roads. There are things we want people to have even if they can't pay for it.

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Boston: Ezra, don't you think when there is a final bill ready and the votes are coming up the president will have a big oval office speech on healthcare? I think they are saving this for the fall push.

Ezra Klein: They may well be. But they may be in less of a position to change public opinion by then.

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Wokingham UK: When the banking house of cards collapsed we the progressive peoples of the free world rushed to put every card back in place and we seem to have done a real good job, with all the old bits and pieces - economies built on rising property prices, staggering inequalities of income, all the big people knowing even better than before that they're too big to fail - functioning like nothing had ever gone wrong. Do we pat ourselves heavily on the back or do we worry that the next collapse will be far worse?

Ezra Klein: I think that depends on how regulatory reform goes in the fall. If we really remake the regulatory structure, then hopefully we've done some real good. If we don't, then we're just in a position where banks like Goldman Sachs are even more central, even more too-big-to-fail, than they were before.

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Lake Riverside, Calif.: Looking back over the past months of the Obama presidency, do you generally give his administration good marks, over all, and feel that in domestic policy, we are on the "right road?"

Ezra Klein: I think they're doing their best. I also think that individual administrations have less control than people like to admit. Congress is a busted institution. The system is biased towards gridlock. They can be doing a good job and not getting much done. Someone walking down the street is going to make more progress than someone walking up a mountain, even though the mountaineer might be trying harder.

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Silver Spring, Md.: Found out that my congresswoman Donna Edwards is having a health care town hall this evening at 6 at the Oxon Hill library. Given that she's a liberal black woman and outspoken in favor of a public option (and who would favor single payer) I'm a little worried about right-wing astroturfers showing up and getting way, way out of hand. What could those of us who support her do to help, do you think?

Ezra Klein: Show up.

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Arlington, Va.: Mr. Klein,

Sorry, most veterans I know and most military retirees think both systems stink. Many of my coworkers who are eligible to be treated by the VA and participate in their retiree health care instead choose to pay for health care as Feds and purchase health insurance from the OPM.

My girlfriend is active-duty military and, sorry, their care is awful.

Please provide the citation for your statement that veterans prefer the VA over private health insurance! I doubt it exists!

Ezra Klein: Link. It says:

"VA medical services received high marks during the annual American Customer Satisfaction Index, which has ranked customer satisfaction with various federal programs and private-sector industries and major companies since 1994.

Veterans who recently used VA services and were interviewed for the 2005 ACSI survey gave the VA's inpatient care a rating of 83 on a 100-point scale -- compared to a 73 rating for the private-sector health care industry. Veterans gave the VA a rating of 80 for outpatient care, five percentage points higher than the 75 rating for private-sector outpatient care and 9 percent higher than the average satisfaction rating for all federal services."

The ACSI, by the way, is not run by the government. It's an independent survey.

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Washington D.C.: As a progressive who strongly wants a public healthcare option (I've given up on advocating for single-payer, which would be my ideal world situation), should I be content with a plan that has no public option but has co-ops instead? How important is it for progressives to fight for a public options? Should we be willing to sacrifice it if necessary for passage of a bill?

Ezra Klein: Content? No. You should try to get the best bill you can and be content with nothing less. Should you kill a bill that will cover 40 million Americans and stop insurers from ever again rescinding coverage or discriminating based on preexisting conditions? Definitely not.

There are two things happening here. One is that reformers are trying to make people's lives better. The other is that reformers are trying to get the best bill they can. If the former condition is met and the latter condition is not, that's still progress.

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Capitol Hill: "The single-payer protesters don't really connect to a larger story, at least not as far as congressional and political reporters are concerned."

So progressive legislators need to be credibly--in the eyes of the media--threatening to block/vote against bills without single payer? Would it be enough to do this with the public plan?

Ezra Klein: Nope. Being willing to kill something is not the same as being able to pass something. Single-payer supporters don't get much coverage because single-payer is not a viable piece of legislation. It doesn't have the votes, nor is it conceivable that it could have the votes sometime soon. To be more clear about my earlier answer, the point isn't that single-payer supporters are getting less coverage because their tactics are poor. They're getting less coverage because they aren't as crucial to the debate as the whole of the Republican opposition.

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Brooklyn, NY: The CW seems to be that if health care can't get done this year, it's dead for a generation. Why wouldn't the Democrats be able to come back after the 2010 election and get something passed? They're likely to pick up 2-3 Senate seats and unlikely to lose significant ground in the House, and would be in a much better position to pass a bill than they are currently.

Ezra Klein: That's not the way these things tend to go. Lose on health care and you've suffered a massive defeat. Defeat makes you unpopular. Slows your momentum. Emboldens the opposition. Suddenly, Republicans look better for 2010. Democrats are afraid of ever touching health care again.

And so on. There have been a couple of times when Democrats have rejected health care bills because they thought they'd win the next election and get something better. This happened under Nixon, and also with Carter. It has never worked.

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Arlington, Va: I can understand Blue Cross employees being opposed to a public option, but why would the people on the street oppose it because, after all, it is an option and is not mandatory?

Ezra Klein: All these things map onto broader political debates. The argument over the public option is not really an argument about the public option. It's an argument about the government vs. the private sector. Democrats vs. Republicans. Liberals vs. Conservatives. There are a lot of strong feelings on the matter and very little in the way of knowledge about the policy. My personal opinion is that the public option won't do nearly as much as its more ardent supporters hope or nearly as much as its detractors fear. It's a useful policy experiment that has, weirdly, come to define the whole debate.

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They're getting less coverage because they aren't as crucial to the debate as the whole of the Republican opposition. : But it's a chicken and egg situation. Are they less crucial to the debate because of lack of coverage?

Ezra Klein: That's one perspective. But I don't really think it's right. I mean, you can't even get consensus for something as mild as a public option to compete with private insurers. Total nationalization of the insurance industry is rather trickier than that. Americans don't trust the government that much.

That said, the room for debate is definitely constrained by the money in the industries and the fact that the media sees its role as reflecting political debate rather than adjudicating or explaining them. I don't know that single-payer would be much likelier in a world where liars are called liars and industry didn't have most of the seats at the table, but I think we'd be better off.

By Ezra Klein  |  August 6, 2009; 1:30 PM ET
 
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Comments

Small quip, could you let peolpe know when your chat's are done? It's NBD, but I could get back to work a little quicker if I don't think you might answer 1 more question.
Thanks

Posted by: obrier2 | August 6, 2009 1:34 PM | Report abuse

Yeah, giving a cutoff time in advance would've been helpful. The site still let me submit a question but then when it reloaded the page said the chat was over. Here's what I wanted to ask, in case you care:

I have no problem with non-profit health care. Actually, I prefer it. But given the government's role in making it artifically expensive in the first place (starting with banning lodge practice, on through the employer-provided loophole & patenting of treatments & procedures), I question the idea that non-profit should = government as proposed plans assume. Ideally I'd like for people to be able to pool resources and ensure access to care with neither state nor corporate involvement. Any thoughts on that?

Posted by: toiletminded | August 6, 2009 1:59 PM | Report abuse

Had trouble getting into the chat as well.

Ezra, Why isn't health care reform being framed as a national security issue? Nic Kristoff and some others hit on this point a few years back.

God forbid we have a pandemic or terror attack we would be lot better off with the populace having insurance and using their respective doctors or clinics than flooding ER's.

Posted by: MerrillFrank | August 6, 2009 2:21 PM | Report abuse

This is an interesting comparison. Medicare in the United States isn't really what I'd consider a single-payer system, since according to MedPac data it covers only about 50% of personal healthcare costs. Canada is much closer to being a single-payer system -- there the government pays about 75% of the costs. In each case, the difference is picked up by private insurance and beneficiaries' cost sharing. Because the coverage gaps are twice as large in the United States' version of Medicare, private insurers play a much larger role. Also, almost one-fourth of U. S. Medicare beneficiaries are in Advantage (private insurance) plans, in which Medicare assigns all of an enrollee's Medicare benefits to the private insurers, who in turn can use the public subsidy they receive to turn a profit. Canada does not assign publicly paid-for benefits to private insurers.

Posted by: wdarmes | August 6, 2009 3:00 PM | Report abuse

"Medicare in the United States isn't really what I'd consider a single-payer system, since according to MedPac data it covers only about 50% of personal healthcare costs."

I have Medicare & I find this hard to believe. Are they counting Medicare Advantage as part of Medicare? How do they figure drug costs?

I think as a practical matter, if you are on Medicare, except for drugs, the vast majority of your costs are covered, but I hate making vague statements like that.

Posted by: lensch | August 6, 2009 5:05 PM | Report abuse

wdarmes - You are correct. Medicare pays 51% of all health care costs for people enrolled in Medicare. But that's a tricky statistic. If you are a vet, but in Medicare, the VA pays for your care, simarly for people in both Medicare and Medicaid. So if you take a person like me who is just in Medicare, it pays more. Looking at the graph, I would say 63% on average. Furthermore the 51% ignores any payment under part D, so I guess it counts all drug payments as under direct spending. If you added in Part D, that would further increase the percent paid by Medicare.

But your point is well taken.

Posted by: lensch | August 6, 2009 5:25 PM | Report abuse

Sorry to keep rattling on, but the 51% figure really bugs me. I think I understand what they did now, and while it has some meaning, you can't use it to compare to Canada.

Suppose a doc would charge you $100 for something if you had no insurance. Suppose he agrees to do it for $50 for Medicare. Suppose Medicare pays $25 of it and you are left to pay the remaining $25. In computing that figure of 51%, MedPac would say that in this case you paid 50% of the cost. But wait, you got a $100 treatment for $25, so actually Medicare paid 75%. That's why I feel Medicare is paying most of my medical expenses.

Furthermore in Canda, there is only one price and I haven't the vaguest notion of how that compares to the various US prices.

So I don't think your comparison is valid.

Posted by: lensch | August 6, 2009 10:42 PM | Report abuse

Medicare is in fact a part public-part private system; with 20% co-pays and no limit on out-of-pocket expenses, private supplemental insurance is a necessity, and all the drug plans are private. Part D is one of the worst laws ever written, and drug costs can still be enormous.

I just got on Medicare this month. My premiums are $346/mo and my drugs will be around $400. This is certainly an excellent deal compared to what an all-private system would cost, but it would obviously still be unaffordable for many people. That is why seniors often cannot pay for the drugs they need and can still go bankrupt from medical expenses.

It would have been interesting to ask the seniors whether they support Medicare for all; I do. They are being told that there will be big cuts in Medicare without being told how this will affect them, so it's only natural that they will be frightened by this (I'm actually surprised that anyone can support the reforms on the table now, since it is so unclear how they will actually work for any of us). I do not want to see the young pitted against the old. Not only would having one system be simpler and cheaper, it would be socially unifying. Why are so many people buying into the need for a war between young & old?

Posted by: debb1 | August 7, 2009 1:27 AM | Report abuse

debb1 - I have been on Medicare for 5 years. I got out my letter saying how much I pay. My Medicare premium is $96.40. I pay an additional amount because I my income is high, but that's not a premium. It's like and additional income tax. I don't know why your premiums are $346 unless you have an expensive supplementary plan. You might check in a couple of years as to whether that plan pays for itself. I did and dropped it 3 years ago.

BTW I agree with you on Medicare for All. We will save $400 Billion a year just by getting rid of the high overhead anf compliance costs of private insurance. And there are many other benefits.

Support HR676.

Posted by: lensch | August 7, 2009 9:49 AM | Report abuse

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