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Seattle: So what exactly did the House put out this morning? Is it the Robust opt-out Public Option that Sen. Reid talked about?

Ezra Klein: No. So to do a bit on defining terms here:

Robust refers to a public option that can use Medicare's payment rates. That would let the public option save 20-30 percent against private insurance. Neither the House nor the Senate includes such an option.

The House bill has a national public option that will set rates in the same way private insurers do (negotiating with providers). The Senate bill has a national public option that works the same way as the House's, save that it has an opt-out feature starting in 2014.


Louisville, Ky.: Hi Ezra,

With the announcement of Lieberman's intent to join the Repubs filibuster and the possibility of other Conservative Dems joining him, do you believe that their colleagues in the Senate and the President will apply pressure at some point which will change their attitude and allow the bill to be voted up or down?

Ezra Klein: Yes. I really don't think Lieberman is going to filibuster this bill. That's not based on anything in particular, it's just my sense from talking to people in the Senate and looking at Lieberman's record. I could be wrong, though.


Fort Worth, Tex.: Out of curiosity, have you looked at John Dickerson's piece about the CBO and deficit neutrality? Here's his example in a nutshell: I tell the CBO next year that I'll win the lottery and then want to buy a $2 million home. CBO says, yes, if you won the lottery, you could pull that off. I then tell everyone that the CBO says I can afford a $2 million house. But odds of me actually winning the lottery are about as good as government reigning in Medicare costs. And that's what's not in the CBO scoring.

Ezra Klein: The problem is his lottery analogy is way off. What he's referring to is this: The government says it will cut X amount from, say, Medicare, using this and that policy. CBO looks at this and that policy, and if they can actually cut X amount, signs off on the numbers. The government could then reverse course at some future date, and that's out of CBO's hands. It has to take the government at its word.

The operative analogy here isn't a lottery. It's a diet. If I tell CBO I'm going to cut calorie intake by 300 calories a day to lose 15 pounds, and they check it and the numbers add up, they can sign off on those numbers. But it's not in their control whether I actually do that.

Baltimore: Ezra: I will be 62 in a couple of months and giving some thought to early retirement if the market doesn't bottom out. However, that means I would give up good employer-provided health insurance. So, under the current Senate and House reform bills, will I be able to get decent health insurance for any sort of reasonable monthly cost? Thanks.

Ezra Klein: Depends how you define reasonable, I fear. You won't get your employer's subsidy, but it will be better for you than it would be right now. In particular, the exchanges will be a help.


Boston: Healthcare reform is like Chinese water torture: endless drip ... drip ... drip ... Lieberman drip ...

When will it stop? It's like the old Schoolhouse Rock song, “I am a bill, I am only a bill, and I am sitting here on Capital Hill ... "

Ezra Klein: To be fair, it is moving. I think that watching the pace of business on the Hill can obscure the actual amount of progress that's happening. But here's what's been done so far:

Five committees draft bills.

Five committees pass bills.

Leadership of both chambers blends bills.

And here's what's left to be done:

Both chambers pass bills.

Both chambers blend their bills.

Both chambers pass the blended bills.

I'd actually say we're most of the way there. The big compromises come in the committee process, not the floor. And it's fairly rare for a bill that's been blended by the two chambers to fail, because without the ability to amend that bill, you can only vote yes or no, and fairly few Democrats are going to want to stand in the party's way.


Early retirement in a couple of months?: How would it affect him at all? Isn't there some clause in these bills that mean they don't even start to do what they do until 2013? What's that about?

Ezra Klein: Well, a lot of the insurance market regulation comes into effect quickly. But I actually hadn't noticed that it was happening in a few months. It's harder to say if the bill would help anyone by then.


Richmond, Va.: "The operative analogy here isn't a lottery. It's a diet. If I tell CBO I'm going to cut calorie intake by 300 calories a day to lose 15 pounds, and they check it and the numbers add up, they can sign off on those numbers. But it's not in their control whether I actually do that. "

Do you know of any entitlement program were the actual cost came in close to the original budget estimates? My understanding is that the major ones (Social Security, Medicare, Medicaid, Medicare Part D [Prescription Drugs]) have all been significantly higher than originally estimated when enacted.

Ezra Klein: Medicare Part D is actually significantly lower than was estimated. Social Security, Medicare and Medicaid were passed decades before the CBO was created, so it's impossible to say for them.


East Lansing, Mich.: One thing I don't get about the state opt-out plan is how exactly does a state decide?

Why would it be better to create the exact same fight going on right now in D.C. but 50 times?

Ezra Klein: What I'm hearing is that both houses of the legislature would have to vote to opt out, and the governor would have to sign it. At the end of the day, I think very few states will actually opt out, because I don't think people will still be yowling about the public option come 2014. Once the controversy of this moment goes, I don't believe it will come back.


Philadelphia, Pa.: I am trying to figure out how this current health care debate will end. Is there a possibility that there could be a compromise that would get enough votes that would settle on a trigger but that increases the conditions upon which the trigger is set off?

Ezra Klein: Yep.


New York, N.Y.: On October 20, volunteers led by Organizing for America flooded Congressional offices with over 300,000 phone calls favoring health reform and the public option. Do you think that effort had much to do with the change of momentum for the public option that occurred last week? I don't believe you've mentioned that event one way or the other.

Ezra Klein: I'm not convinced these big floods of activism move senators one way or the other. I don't know of any votes that changed during August, nor in the last two weeks.


Richmond, Va.: In the House bill, did they keep the millionaire (or whatever the number was) surtax as the method to pay for low income subsidies, and/or add the excise tax on insurers that offer "gold-plated" plans?

On a separate note I presume the prospects for the Wyden amendment and a clean cap on limiting the tax deductibility of health insurance (versus an excise tax on insurers) are still grim?

Ezra Klein: They kept the surtax proposal. It now hits individuals with $500,000 in income and families with $1,000,000. As for Wyden and the tax cap, "grim" is a good word for it.


Re: Public Option: You're being extremely bearish on the public option and exchanges. I think your analysis is pretty good except for the presence of Wyden. Even if he isn't able to open up the exchanges and the public option now, what are the chances he could do so at a later date? I give it good odds because this is a personal cause for him and such things have a way of happening in the Senate, where it seems almost anything can be attached as an amendment.

Ezra Klein: I do believe that the exchanges will open up, at least to employers (though it's not yet clear if an employer who buys into the exchange simply picks the insurance for the employee or actually lets the employee pick their own insurance). Whether Wyden will ever get his way is an open question, at least for now.


Washington, D.C.: Three questions.

1) Approps. The CR runs out at the end of this month, but I know some conference reports have already been passed. Have any of those conference reports been signed by the president yet? And if not all conference reports are passed and Congress decides to do an omnibus, how does that work? Will those approps conference reports be signed into law separately?

2) Healthcare. With a few Senators coming out not in support of Reid's health-care bill, does reconciliation make a difference? Can this be used? I do not understand reconciliation at all.

3) D.C. Daylight savings is on Sunday morning, so you turn your clock back an hour at 2 a.m., does this mean bars in D.C. will stay open an hour later on Halloween???

Ezra Klein: 1) Will have to look into it.

2) At this point, reconciliation looks very unlikely, in no small part because no one understands it.

3) That's an interesting question.


Wilmington, N.C.: Why does everyone assume as a person gets older they need more health care ??? It seems that we have many more drugs that are over-the-counter that were not available way back when to help with minor aches n pains. Plus today's so called elderly are far more educated and active than in generations past. I think this is a ploy that politicians have used in the past to garner political favor. I'm tired of people abusing the medical system by not being responsible for their own health or going to the doctor as a social event. Don't people appreciate how well designed our bodies usually are to live really healthfully for a long time? People are being too selfish thinking only of their own health care and not the country as a whole and not bankrupting it. Young and old persons' attitudes need to change. We need to unlearn some of the stupidities we learn in middle/high school. We have a great nation with many opportunities for all. We need to keep it that way. Thank you for taking my question?

Ezra Klein: It is the case, though, that older people need more health care. The risks for pretty much everything are higher. There's more wear and tear on bones and joints. Higher risk of heart disease and cancer and dementia. Higher risk of diabetes and arthritis. Higher risk of falls and some infections. Etc.


Trying-to-get-a-handle-on-this, MD.: Has the most egregious part of the Senate bill (which you described on one of these chats), dealing with low-income workers, been addressed or fixed in what the House is proposing?

Ezra Klein: My understanding is that it has. The House has a pretty straightforward employer mandate (though not a very strong one), which avoids the problems of the Senate's "free rider" proposal.


Seattle: What's the point of no-return for Sen. Snowe? At what point, if any, has she supported so much of health-care reform that Republicans will no longer trust her even if she backs out?

Ezra Klein: I think that point has passed. She's definitely persona non grata with Republicans, and will probably continue to be. I think the more interesting question is whether Republicans could ever actually drive her out of the party, though it doesn't seem that anything of that nature is happening. She's pretty wildly popular as a Republican independent in Maine.


Fairfax County, Va.: Ezra, I know it's a big day for health care, but I have a quick food question. I'll be spending my Sunday working my sheep herding dogs all day, so I'm going to be exhausted by night. But a friend wants to meet for dinner in D.C. Do we go to the new Birch and Barely in Logan Circle or to the new Againn near Mt. Vernon Square? Or somewhere else? Thanks!

Ezra Klein: Those two are so new I've not been to either. But I'd go to Palena Cafe and order the roast chicken after a day of sheep-herding.


Lawrence, Kan.: Ezra, I find your view that states would not opt of the public option to be reasonable -- for a resident of the East Coast/D.C. area. Why would any state opt out? What politician would withhold something from his/her constituents that others have access to? My worldview was the same when I lived on the east coast.

Then I moved to Kansas. There's no doubt in my mind that Kansas legislators will vote to opt out; there's already a movement to pass a state constitutional amendment to "exempt" the state from any federal health care mandates (that such an amendment itself wouldn't be upheld in court isn't the point).

Hard conservatism, with a strong tinge of right wing Christianity, is the bedrock political view of much of the south, midwest, and west. Ideology is what matters. States will opt out in droves and the citizens of those states, particularly the poor and lower-middle class, will be the victims (as usual).

Ezra Klein: But Kansas also elected Kathleen Sebelius. And it doesn't opt out of Medicaid (though that's in part due to Medicaid's funding structure). E-mail me in 2014 and we'll see who's right.


Brooklyn, N.Y.: I heard you speak at the J Street conference on Monday and appreciated what you had to say about the generation gap and how that affects the conversation about Israel. You mentioned how successful Birthright has been in introducing young Jews to Israel, but I was wondering if you think they do it in a way that opens up the discussion on the complexities of Israeli life vs. shutting it down.

Ezra Klein: Definitely shutting it down.


Princeton, N.J.: I hope you have been the reading the comments on your blog that pertain to Wyden-Bennett (WB). WB gives people vouchers so they have more choice in health insurance, and assumes that competition will then improve health care. Here are some objections to that idea.

The more choice, the more plans, the smaller the pools for each plan. It is obvious that the larger the pool, the more efficient the insurance is. (BTW Medicare for All would have one huge pool.)

The smaller the percentage of patients each plan has, the worse its position in negotiation with providers, thus the higher the cost.

WB confuses insurance choice with medical choice. People want choice of physician and reasonable choice of treatment; they care much less about choice of insurance. Many small plans will each have fewer doctors on their plan because a physician can easily refuse a plan with 1% of the population while they would find it difficult to refuse one with 50% (let alone one with 100%). In addition, small plans will have great pressure to keep down the cost of benefits and thus will restrict coverage and make it difficult to collect.

Finally, as you have remarked, competition does not work for an item you want everyone to have. We have seen that clearly by the example of competitive fire companies in colonial times and in the last 50 years in health care.

Ezra Klein: The problem with this is that it's looking at Wyden-Bennett backwards. The movement is from employer plans, none of which are as large as the exchange, to the exchange. In other words, it helps create a single, massive pool and gives people more buying power than they'd have with their mid-sized employer. So I agree that we should emphasize the importance of size, but I think that militates towards, not against, Wyden-Bennett.


Atlanta, Ga.: Any individual mandate requirement (to buy health insurance) should be inviting a court challenge. "Health Care" is not mentioned under Congress's enumerated powers in the Constitution. Some liken the mandate requirement to that of car insurance, but you could always opt not to drive a car. What next, Congress will demand we buy a Chevy to sustain bailed-out GM?

Ezra Klein: Or they'll demand we buy car insurance if we drive a car? Or abide by laws? Or pay taxes. SOMEONE CALL JOHN GALT!

By Ezra Klein  |  October 29, 2009; 2:14 PM ET
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im sorry i got in late. but the other day, you said that the mass. health care overhaul was extremely successful as an argument for reform. And then you did an odd thing. you talked about coverage, n pretended costs just slipped your attention.
Reading you and immersing myself into the legislations and policy ideas has pushed me from an apathetic cynic of politics to a center-left or even a strong progressive (well, im more of a obama-like pragmatist than ben nelson boy fan). But i was wildly disappointed by that omission. so could you seize the chance to make this right by addressing both sides of the cost issue? that is, out of pocket and total costs (whether it's over budget or not?). n if u don't have enough data about these issues, could you retract your blanket statement for a more burkean modesty?

Posted by: lupercal | October 29, 2009 3:09 PM | Report abuse

“that is, out of pocket and total costs (whether it's over budget or not?).”

Allow me to answer for Ezra because he doesn't usually answer comments.

Q: How much will it cost?

A: About 4 to 5 times more than the initial estimates.

Q: How will it be paid for?

A: By imaginary Medicare cuts and tax increases.

Q: What happens when those cuts don’t occur?

A: We will finance the bill with more debt adding billions of “one thin dimes” to our deficit and then raise taxes (probably a VAT) to pay for it all.

Q: What will happen to premiums?

A: They will increase.

You see, Ezra is advocating that the federal government become a monopsonist (i.e. the ONLY purchaser of healthcare services) and they set the price by fiat which will save lots of money. You know what else saves lots of money? Not being able to see a doctor for several weeks because they all quit and became investment bankers. Another money saving device is death which is usually close to free.

Posted by: kingstu01 | October 29, 2009 5:11 PM | Report abuse

Here's an idea for the insurance mandate whiner: instead of just requiring people to purchase health insurance, we should also give them the option of signing a release form that absolves any hospital of the legal obligation to treat them, even if they cannot pay for the costs. Seems fair. Any takers? No? I didn't think so, moron.

Posted by: daw3 | October 29, 2009 8:10 PM | Report abuse

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