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Washington, DC: A sad hypothetical for you but if Senator Kennedy had been able to be more involved in this whole process, do you think Republican Senators would have been more likely to deal or was it pretty much set in stone that for their own political reasons they were going to oppose any bill on the hopes it would hurt President Obama?

Ezra Klein: Nope. I would have loved to have Kennedy more engaged. But he was engaged in 1994 and the bill flopped. If he were in the room, every conservative legislator in the country would be calling this the Kennedy-Pelosi bill. The one difference is that if he were in the room, there'd be someone who liberals trusted at the table, and someone who could compromise on their behalf with a certain level of authority. As it is, Baucus, Bingaman, and Conrad don't have the trust required to tell liberals that this is the best deal possible.


"medical home" requirement: I'm trying to find out whether any of the pending bills require that insurance plans (maybe only those sold on an exchange?) mandate the use of a so-called "medical home." From what I've read, a "medical home" is the same as an HMO's requirement that you vist your primary care provider (or equivalent) before being allowed to see a specialist. Do you have any information about this provision? Thanks.

Ezra Klein: Nope. There's no mandated medical home in any plan. Though I wouldn't equate the medical home with an HMO, exactly. The medical home is more about coordinating care than gatekeeping care.


New York, N.Y.: I have a question on the "death panels" question. Granted, there are proposals that the proposed health care programs may provide end-of-care counseling. Yet, doesn't such counseling exist under some private insurance provisions? So, isn't the real issue whether or not the government program will pay for such counseling?

Ezra Klein: Yep.


Herndon, Va.: Is there a case for saying that a country that has 47 million uninsured and without access to primary care leaves itself more exposed to disease outbreaks such as H1N1?

Ezra Klein: Very much. We have a uniquely bad health-care system from a public health standpoint. But this has to do with how we view medical care. We tend to see the primary purpose of the health-care system as guaranteeing people's access to dramatic, heroic interventions like chemotherapy or delicate surgeries. We talk rarely about much more important, and basic, things like blood pressure medication and vaccines. But that cheap, basic stuff is also the most effective, and the place where we're leaving the most potential health on the table.


Seattle: What's the end-game for the town-hall screamers? What happens in the end when they shout down all others at these meetings? Are they going to scare Congressmen to vote no, or are they going to convince Congressmen that there is a small, vocal nut-fringe that likes to yell? (Notice I didn't say "their Representative"; that was on purpose)

Ezra Klein: Hard to say. On Mondays and Wednesdays, I think the townhalls will backfire. This is just crankery. It's not representative. Congressman know what their constituents are like. They know what the polling shows. And this is giving moderate Democrats a lot of ammunition to dismiss the skeptics as Palin-esque lunatics who are worried about death panels.

On Tuesdays and Thursdays I think that the point of the townhalls is to make the process look so chaotic and crazed that even if Americans aren't enthused by the nuts on their screen, they're turned off from the whole effort, as it's obvious that no good on something as delicate and complex as health-care reform can come from something as polarized and crazy as this mania.

On Fridays, I'm just not sure.


Grand Rapids, Mich.: What is your take on "Julie and Julia"? I thought the movie was fun, and enjoyed the scenes with Julia Child and her husband (their relationship was interesting). But I found Julie's side of the story to be less interesting and, at times, poorly constructed.

Ezra Klein: Nora Ephron did Julie Powell a disservice. Powell's story is banal in a respectable way: She's underemployed, bored, and young, and she discovers a passion. That doesn't normally merit a movie. But since it did in this case, Ephron had to give the character a conflict. And that conflict was that she was a self-absorbed child.

Take all the stuff about Julia Child "teaching" Powell so much. Child taught her nothing except how to make food. it was Powell who woke up at 5:30am to cook. Powell who kept to a grueling schedule. Powell who kept the blog updated. Powell who developed an appealing writing voice. Powell who didn't stop cooking when she was tired or busy. But in the movie, Powell just gives all credit to Julia, and the movie is constructed to make that plausible. The pity is that it isn't plausible, and it doesn't need to be. The parallel between Child and Powell isn't that they both cook. It's that they found passions. And while it's very good at explaining why Child loved French cuisine, it's too interested in explaining why Powell loved Child to explain why Powell loved writing.


Princeton, NJ: Here is a quote from that well-known expert Ezra Klein:

"I've been attending health-care panels and events on a pretty regular basis for four or five years now. Each event, of course, is its own precious snowflake, with its own set of graphs and bullet points and dweebish jokes. But one thing is perfectly predictable: The Q&A session will be dominated by single-payer activists asking about HR 676.

There's not a mystery as to why this happens: Single-payer activists are very well organized, and they make a point to dispatch their people to these events and get their members to the microphone and ensure that their perspective is heard. But as the bills under consideration suggest, politicians have had no problem ignoring the single-payer grassroots. Max Baucus ruled out their participation on day one. The media hasn't shown the slightest inclination to cover their presence at event after event after event."

Do you believe that if single payer had had more coverage, that if the facts had been written about, that if the media (Post included) had not fallen for the huge PR campaign run by the insurers, that we could have had a more reasonable discussion?

Ezra Klein: I think we could, and should, be having a much more reasonable health care discussion than we are. But the point about the single-payer dominance on Q&As wasn't that they should get all the coverage. It's that different groups organize people to attend these events while the rest of America stays home and cooks dinner for the family. You can learn a lot more from a poll than from a townhall.


Washington, DC: I didn't seem to remember these raw, visceral emotions from health care opponents back when Clinton tried to create a universal program. There wasn't any talk of how "their America" was being taken away. This isn't just about health care right?

Ezra Klein: I think you're misremembering the past a bit. Bus tours were canceled because of fears of violence. Hillary Clinton had to wear a bulletproof vest. Things went nuts in 1994, much as they're going nuts now, This is how the conservative movement organizes against major pieces of liberal legislation. It's not about a particular moment or leader.


Cleveland: Phillip Longman made a convincing case in his book "Best Care Anywhere" that the VA health system not only achieves high quality but is also very effective at managing costs. While he stops short of suggesting that we transition the whole country to a government run system modeled on the VA, he does offer some reasonable suggestions on how to nudge the private sector into adopting the VA model. How closely would you say the bills moving through Congress are aligned with his suggestions?

-I'm assuming you are familiar with them as you endorsed the book.

Ezra Klein: They're not at all aligned with his suggestions. VA is socialized care. The point he makes is that its incentives are thus better than private care: The system makes money by keeping people healthy, not by running more tests. The one exception is that a big chunk of the VA story is the development and use of VISTA, an open source health IT program that's made the VA system much more modern and computerized than most health care. That is something that people are trying to include in this bill.


Washington, D.C.: You know the aphorism, "It's better to stay quiet and let people think you're dumb than to open your mouth and confirm it"? Aren't all these health reform town-hall protesters just doing the latter? Are Americans really that stupid to think that Congress would pass a bill with "death panels" in it?

Ezra Klein: This is actually one of the most confusing parts of the whole issue to me. It's fine and good to oppose health-care reform. But Congress spent years protecting the F-22 because it was popular in a couple of districts. Legislators are famously afraid of polls and industry attacks and angry seniors. But somehow, they're going to vote in favor of death panels?


Fairfax, VA: Ezra, thanks for the chat. Yesterday I analyzed how much I'm paying for my family's medical insurance and was pretty surprised by the result. I'm a federal worker with vanilla Blue Cross/Blue Shield Standard like many feds. I'm a GS-15 so my income is higher than most. When I add both my and my employer's premiums for BCBS, my premiums for dental and vision plans, and my Medicare taxes together, the total is over $16,700. That's before any deductibles and co-pays which add thousands more. It's well over 10% of my compensation with the employer premium included. Last year the total premiums were more than we paid in Federal income taxes.

I don't know how others feel, but I find it outrageous that medical insurance is so costly. And it's going up by double digits each year. I'm relatively well-paid by fed standards, so I'm sure that my coworkers in lower grades find it even more of a burden. And this is for Federal Government health care, leveraged by the Government's buying power.

Do you think that most people, especially those of us with employer-paid health insurance, really understand how much of our money is going to the medical industry? I sure didn't until I added it up. I'd like to have some of my employer's contribution in my pocket instead of in the industry's pocket. Do you think that people would be putting more pressure on Congress to do something about this if they really knew what it was costing them?

Ezra Klein: Nope. Most people see very, very little of how much their employers spends on health care. The worker contribution is generally less than 30 percent. And more to the point, they don't get that the money the employer is paying is not coming out of wages. This is one of the reasons that health care is a tricky political issue. The system is set up to disguise its true costs from people, and so the political pressure for reform is much lower than it would otherwise be.


Chicago: I'm reading Michael Pollan's "In Defense of Food," and must confess to mixed feelings.

I'm more or less convinced of the notion that there are good things in complete, natural foods that we don't (yet) know how to synthesize or add back after processing removes them. And it's perfectly reasonable to think that we might be better off to eat things from which they haven't been removed in the first place.

But Pollan seems positively scornful of the study of nutrition. It's almost as if he's saying that the stupid scientists just don't realize that food is a complex system that they're never going to figure out. I read him to be arguing that every "aha!" moment is sold by the scientific community as THE breakthrough, but I think researchers are typically more modest than that. And more importantly, the "aha!" moments are necessary, incremental steps to better overall understanding.

So is he a crank, or is he a valuable contributor to the discussion?


Ezra Klein: Can he be both?

I had the same reaction to the book, in some ways. Like Pollan, and like the bulk of the evidence, I believe whole foods are better than processed foods, for reasons we don't entirely understand. But I don't think we should be contemptuous of the study of nutrition.

The problem, as I saw it, was that he chose the wrong target. The big problem isn't researchers. It's the way research is reported. Every story trumpets the study its examining as *the* answer. Pollan goes a bit far in the other direction and says they're all crap. The truth is somewhere between, as most researchers would tell you. That said, Pollan is a gorgeous writer with a unique capability to popularize an important subject. So I'm glad he's around.


19th & L: Rahm Emanuel has a reputation as a man you don't want to cross. There were news reports about him shouting at liberal groups who were looking to target Dems on healthcare for example. Now that his brother has become a target, with Ann Coulter last night being the latest to attack, what is Rahm going to do? Is it odd we haven't heard from him on this?

Ezra Klein: You'll never hear from him. The people who will hear from him are the three people whose votes he needs to pass the bill, and the five people who are wavering.


19th and R: With so much disinformation running around these days it seems like fact-checking things like Sarah Palin's Facebook posts has become a larger part of your job. I'm wondering how you decide what to examine? Newt on ABC or Jonah Goldberg at The Corner? If you really wanted to (I don't know why you would) you could spend all day pointing out errors and the such, so how do you prioritize?

Ezra Klein: It's hard to say. Some things seem worth going after. Some things don't. I do try to spend my time on new lies rather than old ones. Death panels was new and thus worth debunking. But the latest missives from Newt are generally stale ideas, and not worth a ton of time. But they're probably more important in the debate. I don't know. For the first time in my life, there's too much health-care policy happening in any given day to write about comprehensively.


Miami: I hate to interupt the Obama love-in, but I'm not a Republican, I'm an Independent. And I'm angry (okay, mildly so) about Obamacare. We have the best health care in the world available in America. It's expensive and too many people don't have access, but it's the best.

But Obamacare promises to destroy all that. We WILL have rationing -- it's illogical to argue otherwise unless we have unlimited spending. We WILL destroy private insurance over time, because corporations won't want to subsidize health care if their competitor's don't. We will stifle innovation because it's so difficult to get a bureaucrat to pay for a new procedure.

I LIKE my health insurance, and I trust my insurance company (ewww that's hard to say) more than some faceless government bureaucrat.

Ezra Klein: Not to get all Spock on you, but this is illogical. We don't have the best health care in the world if people can't use it. The point of a health care system isn't to have moments of brilliance. It's to make the population healthier. As for the question of unlimited spending, the current system is seeing its prices increase far faster than GDP. Trends have it consuming 100 percent of GDP in 2085 or so. Obviously, that won't happen. So at some point, the spending will have to slow. There's not another choice. The question is not whether, but how.

Ad for whether a bureaucrat will choose or decide anything, one thing people have to get real clear on is the difference between a ceiling and a floor. A floor on health care means everyone gets a certain, minimum amount of care. A ceiling means there is some theoretical maximum you can't exceed.

No one -- literally, no one -- is considering a ceiling in health care. No one wants a policy where you can't pay out of pocket for more care, thus retaining a market for the absolute best health care possible at any price. I would literally oppose such a policy. People should be able to spend what they want on health care. They will continue to be able to. What we are considering is a floor on health care, so they have some basic access to care. It will cost about 4 percent -- if it's $1 trillion over 10 years -- of what we're already projected to spend.

Whether you're a Republican, Independent, or Democrat, this bill does some things and it does not do others. A ceiling is one of those things that it does not do.


Washington, D.C.: What do you think accounts for all of the deep-seeded anger at the town hall protests? Judging from interviews with these people, they aren't talking about anything in health care legislation, even fake things in the bill, like Palin's death panels.

Most of them talk in broader terms about how "we're losing the country I grew up in" and "the constitution is being violated." Where do these feelings come from? A general sense of insecurity enhanced by the recession?

Ezra Klein: It's hard to say. Is it a defense of privilege? A reaction against modernity? A fear of Obama? A sense that the world is changing in unstoppable ways? A simple style of opposition?

Whatever it is, it is not actually about health-care reform. Most of the people protesting wouldn't see any changes at all. This is about something bigger than health care.


American ex-pat in London: Whenever I watch President Obama at a townhall I hear him say his preferred method of financing health-care reform is to limit deductions on charitable contributions by the wealthiest Americans. Yet this idea seems to be dead in Congress, as it's not in any of the plans, nor does anyone talk about this as a viable option. Why not? It seems pretty reasonable to me.

Ezra Klein: It's totally baffling. It's an excellent idea that was quickly dismissed by the Senate. There's some chance, I think, that it'll be resurrected when we really need to find financing. But I have no idea why it's not moving towards policy on a smooth and even path even as we speak.


Anonymous: Why is it that so many doctors are opposed to Obama's plan?

Ezra Klein: I haven't seen any good polling of doctors. But in part, it's a simple function of being worried that they'll make less in profits. One reason health care is very expensive is that doctors are extremely highly-compensated. A system that spends less money isn't certain to be a system in which they make less money, but there's some chance of it. Everyone feels much better, of course, attacking insurers and so forth, but if you really want to cut costs, it's actually doctors -- not just profits but behavior -- who are they key.


Military Retiree and loving it: I pay premiums of about $200 per year for my Tricare. I'm seen at Walter Reed. There are no co-pays. I get my prescriptions for free. I'm able to get appts quickly. I got me a pretty sweet deal.

Ezra Klein: Just as a side point to this, Walter Reed is not a VA hospital. It's an army hospital. No operational connection.


San Jose CA: Actually, you're the one being illogical about rationing. We have rationing today: the market is doing the rationing. You want a plan where the government does the rationing.

Both are unfair to someone. You just have a different target in mind.

Ezra Klein: I don't want a plan where the government does the rationing. I want a plan where if the rationing is done, it's done explicitly. The first step, however, isn't rationing at all. It's getting much better evidence so we know what works and what doesn't. The best estimates suggest that 30 percent of the care we use is wasted. It doesn't improve health. If we could cut that out, it wouldn't be rationing any more than it would be rationing to deny me an appendectomy because I have a headache.

Later on, if we need to figure out how to control costs more aggressively, we can decide how we want to do that. But let's actually decide. For now, my interest is in being sure there's a floor so everyone has access to basic care. I have no interest in setting a ceiling, or making decisions about who gets expensive care. We're far from the day when we need to worry about explicit rationing. Right now, we need to the implicit rationing that happens every time someone is turned away because they can't afford good insurance.

By Ezra Klein  |  August 13, 2009; 3:40 PM ET
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Next: What Social Security Teaches Us About Health Care


"Everyone feels much better, of course, attacking insurers and so forth, but if you really want to cut costs, it's actually doctors -- not just profits but behavior -- who are they key."


Posted by: wisewon | August 13, 2009 3:57 PM | Report abuse

San Jose CA: OK, so which is more "unfair", rationing based on a combination of need (irrespective of ability to pay) and marginal benefit (e.g. choosing to save two lives instead of one when the cost is the same) or rationing based on ability to pay? In other words, is it fair for medical outcomes to be a function of wealth?

Posted by: bluegrass1 | August 13, 2009 4:08 PM | Report abuse

Here's an economic lesson. The free market created rationing. It's called the pricing of scarce resources.

Here's the question you should ask yourself: Do you want Wall Street rationing your care based on what's profitable? Or do you want doctors and health care experts rationing based on what will make you healthiest?

And remember all rationing is not the same. Private insurers cap benefits. The government guarantees a minimum level of treatment.

Ceiling vs Floor

Posted by: TheChairman66 | August 14, 2009 1:00 AM | Report abuse

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