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Note: I've deleted the Top Chef spoilers.

Ashland, Mo.: Intuitively the following argument has some appeal: Medicare is going broke. The rate of reimbursement is driving providers out of the program. States can't afford any increase in Medicaid. Adding 10 of millions of patients to these programs makes no sense. What are the counterarguments?

Ezra Klein: The counter, basically, is that private health-care insurance is going broker, faster. Providers really aren't being driven out of Medicare. Medicaid is something of a different story. But private health insurance is seeing the opposite problem: People are being driven into the ranks of the uninsured, and businesses are ceasing to offer coverage. One is no more sustainable than the other in the long-term, and private care is actually seeing faster cost increases than public care.

Meanwhile, other systems don't spend as much as we do, and they tend to have a lot more public involvement. So there's pretty fair evidence that the Medicare model can work well if let loose, but not much evidence that the private market can work for something like health care, which tends to confound normal economic models.

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Portland, Ore.: I'm generally supportive of health care reform, but I'm growing concerned about how this bill affects me personally.

Here's the situation: I have an individual policy that I purchase on the open market. I chose a high-deductible, low-premium policy -- basically catastrophic coverage -- because I have no health problems, I'm careful about my diet and I do my best to stay fit. From what I read online, this type of policy will disappear and I'll have to switch to one with higher premiums and coverage I don't think I currently need.

I understand the importance of mandating coverage, but here's the rub ... I HAVE coverage and it's a policy I'd like to keep. If catastrophic costs are what is bankrupting the country, why would this type of coverage no longer be offered? Am I concerned over nothing, or will I end up paying more even though I have coverage that I'm happy with?

Ezra Klein: Take a look at what Susan Collins is offering today (I summarized it on my blog this morning): She'd ensure that everyone who wasn't using subsidies had access to a catastrophic policy in the exchanges. Some oppose this, as there's a sense that catastrophic policies work until they're needed, and what we should actually be doing is ensuring people have access to preventive care and can go get a lump checked out and all the rest. But I think it's an amendment you'd like.

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Fairfax, Va.: Why are the drugs so much cheaper abroad than here? Is their patent protection different? What is the reason behind the cheaper prices? If we start to import from abroad, won't that negatively affect research and development from these companies, since much of the R&D is funded by drug prices?

Ezra Klein: The governments bargain prices down.

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London, UK: Why do you think there is such unwillingness among Democrats to utilise the so-called "Nuclear option" to end the filibuster for good?

Ezra Klein: Because a lot of individual senators like it, or think that it's important. People are risk averse. They think they'll be in the minority someday, and are more interested in preventing possible irrelevance than acting now that they have a chance.

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Peter, Dallas: What do you see happening when the Democrats lose their 60 seat majority in 2010? Complete gridlock or will Republicans start governing again?

Ezra Klein: Gridlock.

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New York, NY: What do you think are the chances for the new Wyden amendment being introduced today?

Ezra Klein: Hard to say. Depends how seriously Susan Collins pushes for it. At this point, she could get pretty much anything she wants in return for her vote.

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Austin, Tex.: Ezra, I thought I read that the number of senators required to uphold a filibuster was changed from 67 to 60 back in the 1970s. If this is true, what were the circumstances then that allowed this to happen, and are any of those circumstances true now, which might allow it to be lowered below 60?

Ezra Klein: Yep. This happened in the post-Watergate Congress, when the legislative branch decided to reassert its authority over the executive. The problem is that there's no similar sense of institutional identity today. Congress seems perfectly happy being an accessory of the president, and so it's not very worried about its own weakness and decreasing relevance.

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washingtonpost.com: Check out yesterday's chat with the Voltaggio brothers, updated today with nine new answers.

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Brooklyn, NY: Hey Ezra,

A lot of the excitement around the Medicare buy-in consists of a belief (hope?) that the buy-in would continue to pay Medicare rates. If it doesn't, isn't it just a terrible adverse risk pool? Especially if it's only limited to those eligible for the exchanges. Maybe this can be added impetus for expanding the Wyden plan!

Ezra Klein: I'm pretty sure it would. Otherwise, you'd be setting up a whole new program, and no one, so far as I can tell, is really talking about doing that.

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Richmond, Va.: On a related topic, the Federal government is still operating on a continuing resolution for several agencies for the new fiscal year that started in October and an omnibus budget bill is targeted for the end of the year, correct? I assume the usual pork will be attached?

I fail to understand why a Congress with clear majorities from a single party and a President from the same party can't pass the yearly appropriations on time.

Ezra Klein: People really get too caught up in the idea that there are 60 members of the same party. If this was a multi-party system, the members of the "Democratic Party" would inhabit three or four different parties. As it is, we have a two-party system, which means you have fewer parties but less cohesion within those parties. But put Anthony Weiner and Ben Nelson in a room together, let them talk out some issues, and see if it still seems odd that Democrats have trouble passing stuff.

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Washington, DC: Given the excise tax inclusion in the final bill driving down benefit levels, Obama's promise that if we like what we have we can keep it seems to be empty.

Ezra Klein: Why? You can keep what you have. In 10 years, as cost pressures hit the system hard, what you have will change. That's true with or without the excise tax. Part of the problem with Obama's "keep what you have" promise is that it seems to set him up as the alternative to stasis. But there's no stasis. It's the change the Democrats are offering versus the changes that the accelerating deterioration of the system will ensure.

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Portsmouth, N.H.: It's my impression that the Democrats do an incredibly bad job of defending perfectly defensible positions. For example, is there any reason they don't seem to respond to the Republican charge that they're "rushing" health care reform by pointing out that the problems facing the uninsured/underinsured have been around for decades and if the Republicans HAD dealt with them when they were in power, we wouldn't even be having this conversation? Or do they say that and it doesn't get covered?

Ezra Klein: Or both? You've got 535 members of Congress, and more folks in the admin, the media, etc. It's a lot of people saying a lot of things, and the media doesn't report the vast majority of them. I guess you could wonder why there isn't a national ad campaign on this point, but I think it's basically because the Democrats don't think it matters. The Republicans aren't going to cooperate and the conservative Dems don't care what Bush does or doesn't do.

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Brandon, Philadelphia: With a new Congress and White House, why not revisit the prescription drug plan and pass a change that allows the government to negotiate the prices?

Ezra Klein: The answer, sadly, seems to be that they cut a deal with Pharma to ensure the industry's neutrality. They got that neutrality, but then they couldn't squeeze them as much as they probably should've.

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Culver City, Calif.: What are Gregg & Conrad thinking with the deficit commission? That can't possibly work as they designed so why are they proposing it? Is it just a cheap publicity grab for them or do they seriously believe that Congress needs larger supermajorities to be effective?

Ezra Klein: I think they're serious about this issue, and they probably had to make these concessions to bring people onto the bill. What I don't really understand is why they didn't scrap this idea once these concessions proved necessary.

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The rate of reimbursement is driving providers out of the program: Latest figure from MedPac:

96.8% of physicians will take new Medicare patients.

Ezra Klein: And there it is.

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Richmond, Va.: "Ezra Klein: Yep. This happened in the post-Watergate Congress, when the legislative branch decided to reassert its authority over the executive. The problem is that there's no similar sense of institutional identity today. Congress seems perfectly happy being an accessory of the president, and so it's not very worried about its own weakness and decreasing relevance."

I would argue that the 1994 Republican Congress, at least until 1998 when Newt left had a pretty good sense of institutional identity. For all the talk of 60 votes, I find it hard to believe that if the Republicans had identical majorities and a Republican President they wouldn't find a way to get their agenda through.

Ezra Klein: I don't agree. They had a good sense of partisan identity. But they weren't concerned with the power of Congress as an institution. If Gingrich had become president, the House would have existed to serve him.

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Arlington, Va.: Ezra,

How surprised are you that with the Medicare/Medicaid expansions and the possible Wyden amendment to open up the exchanges, we might end up with a much better bill than we had a week ago? Did you see these developments among the potential compromises?

But here's my other question/concern: what do you expect these changes will do to the cost of the bill? I worry that if it comes back and it's not budget-neutral the first place Senators will start cutting is in the subsidies.

Ezra Klein: Very, very surprised. Brad DeLong had a good line on the shift: "Another defeat like this," he said, "and we just might win!"

The changes under consideration should lower the cost of the bill. Subsidies for Medicare are cheaper than subsidies for private insurance, as Medicare is cheaper than private insurance. Wyden's plan has already been scored as a cost saver. Etc.

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Medfield, Mass.: Why are 10 Democratic Senators bargaining away the public option with themselves -- without Lieberman or Snowe in the room? Having a hard time understanding why Lieberman or Snowe weren't part of these negotiations.

Ezra Klein: Lieberman was invited, but he refused to attend.

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Hoboken, NJ: I've been reading articles on both Huffington Post and DailyKos by progressives that insist that health care reform without the public option is just a giveaway to the insurance industry and would make things worse. I know you do not agree with this, but what is the argument (with evidence to support it) that this isn't true? Thanks, as always, for your insight.

Ezra Klein: I'd ask the opposite: What's the evidence that it is true? You could argue it's a giveaway to the insurance industry, in that they get new customers so long as they cease discriminating. But on that count, so what? If they start acting better, than it's good that 35 million people suddenly have insurance. The bigger question is whether this will "make everything worse," and I think that's just unbelievably wrong. Progressives thrill to Alan Grayson saying that people die from lacking insurance and then are willing to trash an opportunity to prevent those deaths?

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Los Angeles: I'm afraid that liberals look upon the Medicare Buy-in as an opening for single-payer. What about those of us who do want universal health care but don't think single-payer is the way to go? Why do prominent liberals always act as though single-payer is the only way to go and ignore those on their own side who think otherwise?

Ezra Klein: If this is a step towards single-payer, it is small and slow. But I think it is a step towards more directly understanding that government can get better prices in the market, and that that's one way we can eventually save some money here.

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Chicago: There has been talk of skipping conference committee and just calling the Senate deal go get approved by the House and signed by the President. How likely is it that we see no change to the Senate bill once it's approved? What about Stupak?

Ezra Klein: Extremely unlikely. I'm not giving this possibility much attention. It seems like wishful thinking to me.

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New Haven, Conn.: I know the common wisdom is the Beltway is that stripping Sen. Lieberman from his chairmanship of Homeland Security Committee is a bad idea since he'll be in a huff and won't work or vote the Democratic leadership (as opposed to now?)

But one point that's forgotten is one reason Connecticut keeps sending Sen. Lieberman back to Capital Hill is that he appears to have influence there. If he lost his chairmanship, it's a signal to the Connecticut electorate that he isn't as influential as he tells us he is and sending a freshman senator would be in our better interests then this political pariah.

Ezra Klein: Well, we'll see if they send him back again. But more broadly, I'm skeptical that voters make extremely tactical decisions based on the powers granted by seniority.

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Miami: Ezra,

I thought I've followed the health care reform process pretty closely (thanks largely to your wonderfully informative blog), but I found myself confused this morning by your post on the Wyden-Collins amendments. Specifically this:

"Right now, the exchanges don't permit employee choice. If your company buys into the exchange, it doesn't mean that you and your colleagues get to pick the plan that best fits your needs. It means your HR department picks a plan for everyone. Wyden would let employers choose to give their workers a voucher that the employees could use to choose their own insurance plans."

My understanding was always that companies couldn't buy into the exchange at all. I thought the exchange was precisely set up for people who do not get insurance through their employer. Can you clarify this?

Ezra Klein: Small businesses -- and eventually, larger businesses -- can buy from the exchange. So Bob of Bob's Auto, with 18 employees, can head to the exchange and pay to purchase Blue Cross standard for all. But Bob makes the insurance choice for all of them. Wyden wants to let Bob gives his workers a voucher which pays a certain percentage of costs on the exchange, and uses pre-tax dollars.

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Arlington, Va.: Why can't the insurance industry discriminate? If you have too many accidents, your car insurance company will drop your car insurance and you will have to find new expensive way of insuring yourself. Insurance is a business.

Ezra Klein: Yes, but we don't really want it to be a business. At least, we don't want it to be one if it impedes our ability to get medical treatment. So insurers either need to figure out how to make a business out of providing insurance to everybody or they can let the government come in and take the industry over, as happened with Medicare.

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Washington, D.C.: Any reasons why Democrats have painted GOP as opposed to reform, instead of incorporating GOP ideas and trying to please 1-2 Republican members?

Ezra Klein: Enzi had 41 amendments accepted into the bill and was a member of the gang of six that wrote the Finance Committee's legislation. At what point does it count as "incorporating GOP ideas?"

By Ezra Klein  |  December 10, 2009; 1:44 PM ET
 
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Comments

I'd like to see proof that private insurers are "going broker, faster".

I don't believe it.

Congress recently tried to get detailed info regarding private insurer profits but was rebuffed.

Private insurers are steadily weening themselves off of the aged, the ill, and the infirmed, with their goal being to insure only the young and the healthy. Once the gvmt and the corporate media allows that to succeed, the insurers will be content to milk that cash cow for as long as possible and enjoy whatever profits they manage to achieve under that model. And rest assured that model will deliver profits, not losses.

Posted by: Lomillialor | December 10, 2009 2:21 PM | Report abuse

Hey, Ezra:

On the question from Portland, wouldn't the Oregonian's current catastrophic policy just be grandfathered, and he/she would get to keep his coverage -- regardless of the minimum level of coverage? Now if the Portlander changed his/her policy, then he/she would have to buy a greater level of coverage. But the Oregonian would still get to keep his/her policy if he/she didn't change policies.

Posted by: BradGabel2002 | December 10, 2009 2:31 PM | Report abuse

Lomillialor, in the short hand of the chat setting, I think that the point got missed. Private insurers aren't going broke; they're going to make everybody else go broke. The argument is that, left unchecked, premium growth rates will one day consume the entire GDP.

Posted by: JEinATL | December 10, 2009 2:37 PM | Report abuse

Is her vote in play?
With Leiberman stabbing us in the back (he really wouldn't even come to negotiations?), it seems it may be needed.

Posted by: adamiani | December 10, 2009 4:20 PM | Report abuse

What's happening to private insurers?

More and more employers are dropping coverage. More individuals are dropping or losing coverage.

As there are fewer people with good insurance, fewer visit doctors so often...

Doctors get less traffic.

Doctors raise prices some.

The cycle continues.

Private insurance is beginning to crumble, break down.

This is part of a bigger picture:

http://findingourdream.blogspot.com/2009/10/great-american-health-care-bubble-or.html

Posted by: HalHorvath | December 10, 2009 4:21 PM | Report abuse

thanks for letting us know at the top that you removed the tc spoilers. i first opened this post with one squinty eye. ;)

Posted by: schaffermommy | December 10, 2009 7:52 PM | Report abuse

It's looking like the new compromise might not survive as Snowe doesn't like the Medicare expansion and Lieberman doesn't like the trigger (and is making noise about Medicare too).

What if both the trigger and the Medicare expansion are scrapped but we have the new national nonprofit plans pay Medicare based (+5 or +10% or even higher) rates? Snowe might still have problems, but if rates are set high enough she might be on board. Progressives get the Medicare rates they've been hoping for. Of course, who knows what the hell Lieberman wants.

From a policy standpoint, this completes J.R. Reid's trifecta. In his study of quite different universal health plans around the world, he points out they are all similar in that they (1) require everyone to have insurance and provide subsidies for those who can't afford it; (2) base their insurance on nonprofit plans; and (3) the government sets rates. It would be nice to get that 3rd box checked, even if we let the plan set quite high rates to begin with. Let's get the precedent in place.

Is this doable?

Posted by: glen5 | December 11, 2009 8:45 AM | Report abuse

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