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Ezra Klein: Happy day-after-the-CBO-score day! Presumably, you're all suitably hungover from celebrating the arrival of estimations on health-care's impact on the 10-year budget window. Let's do some questions.


Ashland, Mo.: There have been a few articles contending that state efforts at health reform have failed to meet objectives. Do you agree with that analysis? Are those efforts relevant to the Congressional proposals? If so, why will the Congressional proposals succeed where the state efforts failed?

Ezra Klein: I agree with those articles, and in fact wrote one of them. The main reason state efforts fail is that most states are constitutionally required to balance their budgets. That means that when recessions hit and revenues drop sharply, they have less money to spend on health-care reform. But at that same moment, health care becomes more expensive because more people are out of work and need subsidies. That tends to kill the program in question.

The federal government, however, can deficit spend, so it doesn't have this problem. It also has a lot more regulatory power, and from a broader reform perspective (as opposed to paying for coverage perspective), can force a lot more changes to the overall system. NEXT!


Arlington, Va.: Can you explain a little more about the CBO report regarding the cost of health care? How will this overhaul reduce costs and the deficit? And why the rush to completely overhaul things? Wouldn't incremental changes protect against the unintended consequences that usually result when Congress tries to act on too grand a scale?

Ezra Klein: What the CBO report says is that Congress isn't acting on a grand scale, much less "too grand" a scale. This plan is less ambitious than Clinton's plan, than Nixon's plan, and than Truman's plan -- and that's true even though the system is much worse than it was in the past. This plan will reduce the deficit over 10 and 20 years, and it will only change the insurance situation for 37 million people: 29 million of whom would've been uninsured, and five million of whom would've been on the small or non-group market.

In other words, what the CBO said is that this is an incremental plan where the numbers add up. NEXT!


Louisville, Ky.: Ezra, can you shed some light on the process involved in moving the Health-Care bill through the Senate? I've heard bits and pieces about number of votes required, but would like some clarification about: voting to block filibuster in the Senate, taking the bill back to a joint Senate-House conference, then back to the floor for final vote. Would you expand on this? Thanks.

Ezra Klein: Sure. Next move is the Finance Committee vote on Tuesday: that requires a bare majority of the committee (I think that means 11 votes, but that's just memory). Then Reid and the Democratic leadership blend the HELP and Finance bills into one bill. That doesn't require any votes. Then the bill comes to the floor. It'll need 60 votes against a filibuster, and 51 votes in favor of the legislation. NEXT!

Princeton, NJ: Has anyone (CBO or thers) costed HR676?

Ezra Klein: CBO hasn't yet, but my understanding is that they're in the process of doing so now. NEXT!


Ezra Klein: If you live in DC and go to the Juice Joint for lunch, do not get their white bean salad. Very bland. Blech. Also, I'm going to stop saying "NEXT!"


Boston: What is it going to take politically to actually bring healthcare costs down? A Democratic president, House and Senate aren't getting it done right now. Will we have to be on the brink of national bankruptcy (foreigners unwilling to extend us a national credit card by funding our debt anymore) to face up to this with enough political will/necessity to change?

Ezra Klein: That's pretty much my guess. Or our political system will need to discover its conscience.


Chicago: So Ezra, you're a foodie, have you ever been to Alinea? This story about Grant Achatz in the Atlantic yesterday being able to cook without a sense of smell is very Beethoven.

Ezra Klein: I want to go to Alinea more than any restaurant in the country. And that article on the Atlantic food site is incredible.


Philadelphia: You mostly seem positive about health insurance reform, despite its weaknesses, because you think it lays the groundwork for further reform down the road. Didn't we already have the groundwork for good reform in the medicare system? If politicians were unwilling to base healthcare reform on expanding medicare, what makes you think they will be willing to expand the current legislation, including the exchanges, in the future?

Ezra Klein: That's a fair question. For one thing, some of the policies in here expand automatically. Baucus's bill, for instance, brings all employers into the exchanges in, if I remember, 2022, so that happens on its own. The bill also, through the individual mandate, creates a national expectation and policy of near-universal health care, and just as Medicare hasn't been rolled back, I don't expect that will be rolled back.

So there are two answers, I guess. One is that I think this bill is well worth doing even if it never expands. The second, though, is that it creates an underlying architecture for expansion. Remember that Medicare started quite small, and grew over time. It expanded horizontally (to prescription drugs, etc), just not to different age groups. This bill works for all age groups, and might expand horizontally too. In any case, it certainly makes it easier to do.


New York, N.Y.: Just out of pure curiosity, have you ever lived in a "red state" before?

I asked because you posted about your support for the new idea that each state can opt-out of letting its residents get a government-run insurance.

As somebody who could well still be a slave if "state's rights" were giving too much weight, I hesitate. But you do get that a lot of uninsured people live in red states? They're low-income, they're rural, they're non-White, they're everything national Liberals claim to be wanting to help. Yet I was a bit shocked at how much you seemed to like this idea. I didn't like when Sarah Palin divided up the U.S.A. into good and bad parts, and I don't like it when anybody else does either.

Ezra Klein: It's not good and bad. It's liberal and conservative. I like a national public option available to everyone better than I like this idea. But because of the politics of those states, that doesn't seem possible, and I don't have the power to make it possible. This isn't about what I "want." You try to advocate for the best you can get. My expectation is that if the policy works in controlling costs, red states will adopt it, too.


College Park, Md.: Where do you work-out in D.C.?

Ezra Klein: At the place where I've purchased a gym membership.


Nashville, Tenn.: Whose stuff are you reading on the healthcare debate?

Ezra Klein: Jon Cohn, Karen Tumulty, and Igor Volsky are all doing good work, as are many other folks. Also, serious congressional outlets: Roll Call, the Hill, Congress Daily. They've got the best and most useful information on the congressional machinations right now, and that's really where the action is at.


Washington, DC: Where do you buy Szechuan peppercorns in DC (without driving)?

Ezra Klein: You don't, as far as I can tell. But there is a place I go near, I think, the Wheaton metro in Maryland. Search for "Full Kee" restaurant. It's next door to them.


San Francisco, CA: IF the finance committee's bill doesn't change too much in conference with the HELP committee but it gets a decent public option how do you see that affecting the CBO score?

Ezra Klein: Positively, though only mildly so.


Silver Spring, Md.: Does Mike Isabella's general aura of reality show douchiness make you less likely to eat at Zaytinya?

Ezra Klein: Yes, although I've never liked Zaytinya anyway. I love Jaleo, and Oyamel is growing on me. But I've found Lebanese Taverna to be a similar level of Middle Eastern food, and much cheaper. But then, I haven't been there in a few years.


Culver City, Calif.: How important has liberal lobbying on the public option been in keeping that part of HRC alive. The liberal revolt over the public option seemed like suicide to me back in August but the public option is some form has survived and so has HRC. Would this have happened anyway or was the liberal revolt crucial?

Ezra Klein: I think the liberal revolt has been a crucial part of it. Without that organizing, the idea would be dead. And I say that as someone who has, more than a few times, been on their bad side.


Silver Spring, Md.: "Then Reid and the Democratic leadership blend the HELP and Finance bills into one bill."

Will the CBO review this "one bill" before the whole senate votes?

Ezra Klein: Yep.


Washington, D.C.: How does this sound for a health care endgame? The Senate Finance bill is merged with the HELP bill, with the addition of a public option with an opt-out provision for states. The finance pay-fors are kept in the bill. The House passes a bill with a public option based on Medicare rates plus 5% (if they can )or negotiated individually with providers, and includes it's version of revenue raising (surtaxes on the wealthy). Then they get into conference, and come out with a public option with an opt-out, and a mixture of House/Senate Finance revenue. You can keep House-level subsidies, and let the Baucus $81 billion surplus come down a bit. Does this sound realistic to you?

Ezra Klein: Well, you'd have to cut the subsidies by a bit more than you're saying. I think you end up with some form of excise tax plus some form of itemized deduction limit. But that scenario seems basically right to me.


Chicago: I've read a lot about the exchanges, but I still feel like I don't have a very good grasp on how exactly they would work. To the best of my understanding, in a national exchange people would contribute a certain amount of money and then, subject to age and location, be able to pick from a selection of plans at that price level. These plans would likely be negotiated by a government representative who has the bargaining power of all the contributions in the insurance exchange to work with. How far off is my conception?

Ezra Klein: You're right up until the bargaining. As I understand it, you're more dealing with a situation in which participating insurers would offer bids, and the idea is that competition, not government bargaining, would bring prices down.


This bill works for all age groups, and might expand horizontally too. : So you believe we can have an efficient high quality system like other countries and keep for profit competitive private insurance?

Other countries that kept private insurance have either made them non profit (Switzerland) or prevented them from competing on the basic plan (Netherlands et al).

Ezra Klein: Not really. But, then I don't think we're going to get an efficient, high quality, affordable system like they have in other countries.


Alexandria, VA: Is China still buying our debt? I heard that they had diversified into Australia and Japan.

Ezra Klein: Australia has a lot less debt than we do.


Washington, DC: I heard someone describe the health care exchanges as an '' for insurance. How accurate is that likely to be? As someone who just got kicked off of my parents' insurance, I'm finding that just getting a simple quote on how much insurance would cost me out of pocket & what it would cover is a ridiculously painful process. If I could just go to a .gov site, enter my demographics, and get rate quotes from a few different providers, health care reform would already be a success in my book. Is that what the future looks like?

Ezra Klein: Yep!


London, England: As a Brit trying to understand the proposed reforms, it seems to me that a truly terrible outcome would be an individual mandate without a public option (i.e. a mandate to buy expensive insurance). I realize there are subsidies for low income people, but it seems that a mandate minus the public option isn't a sensible way to achieve universal coverage. Am I wrong?

Ezra Klein: I don't think any of the public options under consideration (ie, any public option that doesn't bargain at Medicare rates) will have a substantial impact on premiums. You can say that we shouldn't, in principle, demand people purchase private products (or pick pickled peppers), but I don't think the issue here is affordability between a system with and without a level-playing field public option. A level-playing field public option is another way of saying a public option that doesn't save much money.


Seattle, Wash.: You have a gym membership? You actually go there more then once a year?

Aren't journalist sorta known for lack of exercise?

Ezra Klein: Just trying to practice what I preach and lower national health expenditures.


Athens, Ohio: What do you think the chances are that Reid adds the employer mandate in the merger between the HELP and Finance bills? Would that significantly change the CBO score?

Ezra Klein: Not insignificant. That would improve the score and up the coverage level. It would also mean the end of the awful free rider policy in the Finance bill.


Helena MT: At what point will the Democrats realize that they have 60 votes in their caucus and can prevent filibusters simply by keeping the caucus in line on cloture? I would think there are sticks/carrots that could be used to keep the Lincolns, Nelsons, and other conservative Dems in line on cloture. Why would any member of the caucus vote against the leadership on cloture?

Ezra Klein: They don't seem able to reliably do that to Nelson and Lincoln. My sense of Congress is that people think the president and the leadership have a lot more power over Ben Nelson than they actually do.


Zaytinya and unrelated Pet Peeve pertaining writing on health reform: First, to be fair to Zaytinya, Mike Isabella, I thought, was no longer there. I was led to believe that he's heading up a new venture in LA for Jose Andres. Second, as a Public Health professional with an MPH and on my way to a doctorate, it's disappointing to say the least to see reporters continue to fail to interview Public Health Professionals, ie. those trained to analyze and comment, for their opinions with regard to all aspects of health policy. It is us, not physicians, who analyze the effects of policies on health. Physicians can give you anecdotes, we give you the facts as demonstrated by analysis. We are the ones comparing medicaid rules from state to state to see if there are different outcomes, we are the ones developing programs to improve health and wellness for whole communities. Physicians can treat one person at a time. We treat communities. We are not all physicians or nurses or in any way clinically trained, so please ask your doctor not me, if you're experiencing pain in your elbow. Likewise, if you want to know the effect of tort reform on malpractice rates, ask me not a physician.

Ezra Klein: The new venture is Bazaar, and that was being headed by Brian Voltaggio. But he left Bazaar after the show began to go to a place called the Dining Room. Isabella is still at Zaytinya, as I understand it.


Los Angeles, CA: Do you really think Israel's military operation in Gaza was unjustified? What do you think Israel should have done given the rockets flying towards its towns from Gaza?

Ezra Klein: Rockets that had killed nobody and were a response to an economic embargo that Israel had put on Gaza (just as the embargo was a response to Hamas's crimes, and so on back into the rabbit hole of this conflict)? Not sure. You could ignore them. You could lift the embargo. You could do nothing. But pummeling a crowded urban area with missiles? That wasn't needed, and I see no evidence it advanced Israel's interests.


Brooklyn, NY: I am moving to D.C. in a couple months and thinking about getting a place in Mount Pleasant. What are restaurant options like there?

Ezra Klein: Pretty good. Red Rocks is nearby. Mt Pleasant St. has lots of great Mexican and Salvadoran food. It has Tonic, a decent bistro, Dos Gringos, a good cafe, and Radius, an uncommonly good (for DC) pizza place. It's near Columbia Heights and Adams Morgan. I love Mt. P.


Tempe, Ariz.: I admit it. I used to watch Dawson's Creek back in the day. Oh Joey.

Just curious, what's your lame-brain teenybopper soapy show?

Ezra Klein: I like the NBC line-up: The Office, 30 Rock, and Community. Beyond that, it's mostly cooking shows.


Fairfax, Va.: Ezra, a couple weeks ago the Office of Personnel Management announced 2010 premiums for the Federal Employees Health Benefits program. Rates are going up 8.8% on average. Premiums for Blue Cross, which covers 60% of feds and retirees, are rising 12% for families and 15% for singles.

The Post covered this only in the Federal Diary, so relatively few people outside the fed community saw it. Shouldn't this have been front page news? I realize that few people outside the government care about federal workers, but isn't this a big deal in the health insurance debate? Here's why I think it is.

First, the FEHB covers millions of feds and retirees. The government (we the taxpayers) covers the employer's share of the premiums, which is a little under 70% of the total. That BCBS family plan increase will translate into an $1100 jump in Uncle Sam's contribution for each of the feds and retirees enrolled in the family plan. These rate increases will cost us taxpayers several billion dollars more next year.

Second, the FEHB has been touted as a model program. But if this is the best deal OPM can get, what's in store next year for everyone else? Are feds the canaries in the coal mine here? The current debate and reform proposals sure don't seem to have modified the behavior of the insurance industry, at least where rates are concerned. Maybe they need this added revenue to pay for the lobbying it's taking to ensure they kill off any real reform.

Your thoughts?

Ezra Klein: Everything you say makes sense. The failure of FEHBP to really control costs is one of the biggest arguments against the exchanges.


DC: How much of the carbon footprint discussed in your article is red-meat? Does my eating chicken still destroy the planet? Meat Facts

Ezra Klein: Chicken is better than red meat, worse than eggplant.


Nashville: My congressman, Jim Cooper, is holding out hope that HR 1321 (Wyden-Bennett) will be considered. He opposes HR 3200 but says he'd support adding a public option to Wyden-Bennett.

Three-part question: 1) Is there any real possibility that Healthy Americans Act will get serious consideration? 2) What would it take for HR 3200 to get transformed into something like Healthy Americans Act? and 3) Do you think this has any real chance of happening?

Ezra Klein: 1) No. 2) Not gonna happen. 3) No.


Washington, DC: Mr. Klein,

In your posting you say that under the bill being considered, nothing will change for the vast majority of Americans. It seemed like you thought this was a bad thing, which I thought strange, considering the majority of Americans are satisfied with their coverage. Do you think it's a bad thing?

Ezra Klein: Yes. People are satisfied because they don't use their health insurance and they are insulated from its costs. They are not satisfied, however, with wage stagnation, which is largely a function of compensation dollars going to fund health-care premiums. They are not satisfied with the country going bankrupt, or with employers ceasing to offer insurance, or with huge deductibles. That;s why people say they're satisfied with what they have, but deeply unsatisfied with the system.


Washington, DC: So here's a question I haven't seen answered about how the exchanges will work: will the exchange (or exchanges, I suppose, if every state gets one) -replace- the individual market, or just sit alongside it?

From what I've read, it doesn't seem like the Wild West individual marketplace for insurance is going away; the exchange is just going to be an additional place to buy insurance. This seems ripe for insurance company gaming, though: why wouldn't you create incentives for your brokers to steer the healthy to the unregulated individual market, and steer the unhealthy (or older) towards a similar product in the exchange? The end result being higher premiums in the exchange, more and more people bailing out into the same broken individual market with no guaranteed issue and the possibility of recissions, until the exchanges eventually fold.

Please tell me I've just missed the piece in the legislation where it says, "Insurance companies cannot sell individual policies outside the exchange." Or, second-best, something about the amazing risk adjustments the federal government is going to do to balance costs for comparable policies inside and outside the exchanges, so we won't see adverse selection torpedo this attempt at reform.

Ezra Klein: Replace, is my understanding.


San Diego, Calif.: Ezra,

One of the criticisms of the bill going through congress that really rang true with me was that the $900 billion price tag was misleading because the spending didn't start until a few years into the bill, but the revenue collecting began almost immediately. On the other hand a 10 year analysis begun the year coverage started (which seems to me a little more honest) had the cost almost 50% higher.

So, is the pricetag from the new CBO bill for the next 10 years, or for 10 years of the full program being implemented?

Ezra Klein: In order to answer this, CBO also estimated the second 10 years of the bill (so 2020 through 2029). They said that deficit reduction will accelerate over that period.

That's it for me, folks. See you on the blog!

By Ezra Klein  |  October 8, 2009; 1:29 PM ET
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Why read Karen Tumulty? Go straight to the White House talking points.

Igor Volsky has skills, but Think Progress has a serious credibility problem with John Podesta at the helm.

Posted by: bmull | October 8, 2009 9:24 PM | Report abuse

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