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Chicago: Do you think that Ben Nelson can be persuaded to walk back his Nebraska subsidy deal with Harry Reid because of the pending suit by a number of governors of other states which questions the constitutionality of such a deal? And, also in light of the fact that many Nebraskans are very embarrassed and angry at Nelson for his prima donna moves that threatened to destroy the health care bill altogether?

Ezra Klein: My understanding is that the more likely outcome is that he -- and Reid -- walk it forward: All states get the Nebraska deal to have the Feds fund the Medicaid expansion, not just Nebraska.

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N.Y., N.Y.: You seem to be slowly shifting the focus of your posts from health care to other subjects, including the cap & trade legislation now pending in the Senate. I would be interested in your response to those who argue that a straight-forward carbon tax is a more economically efficient approach to reducing carbon emissions than is cap & trade.

Ezra Klein: It's a bit like saying single-payer is a cleaner approach than the health-care reform bill. it's true that I can make up a carbon tax that's more efficient than what the cap-and-trade plan the Congress is likely to pass (if it indeed passes such a plan), but if I then gave my carbon tax to the Congress, it would either 1) die or 2) become really complicated and clunky and unsatisfying.

We saw evidence of this in France, actually, where their Constitutional Council threw out their carbon tax because it had too many loopholes and exempted too many polluters (in France, there's apparently a constitutional right to "tax equity"). If a carbon tax can't remain pristine even in France, it certainly will not look so clean and elegant when our Congress finishes with it.

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Question for your inner parliamentarian: Ezra: As a Massachusetts resident who's closely following the Senate race, I actually think Coakley's going to prevail in the end. But, what if she doesn't? I know you've mentioned the possibility that Democrats in both houses could simply speed things up if need be, or, alternatively, the House has the option of passing the Senate bill as is. But what I've been wondering is: do you know if it's possible, in the event a melded bill falls short in the Senate (I see Ben Nelson's been making troubling noises again), for the House to still act on the original (ie., non-melded) bill that was recently passed by the Senate? Is such a procedure permitted, or does the melding (or conference) process render the original bills "dead"? Any thoughts?

Ezra Klein: I'm just not convinced it's a big legislative problem for health care. But it could be a political problem: It changes the narrative, forces the Dems to push the bill through on a rapid basis, and generally makes an already ugly process a whole lot uglier.

As for whether the House could simply act on the Senate bill, absolutely. They could pass the Senate legislation unchanged, and then the bill would go directly to Obama, skipping the Senate altogether. Revisions could be done through the reconciliation process, or, if they could find the votes, another bill next year.

Washington, D.C.: One thing that most threatens the Obama agenda is that the American public still has deep-seeded, but incorrect assumptions about things. Take for example, the idea that the "government should tighten its belt" during a recession, or that the deficit is caused by discretionary spending. How do we break through these assumptions? What can Obama do to change the way people think about things?

Ezra Klein: No idea. This is, in theory, why we have a representational government, rather than a weekly referendum on "things the government is doing." We're supposed to elect folks who study up on this stuff and then make the decisions we would make if we were more informed. Instead, we get hacks who pander to our ignorance because they want to win reelection, or retake the majority, or run for Senate. Or maybe because they're ignorant, too.

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Anaheim, Calif.: Do you agree with Reid, who reportedly said – essentially -- that it was a mistake to pursue a 60 vote strategy on health care?

Ezra Klein: I don't think he said that. Unless you have another comment in mind, he said Olympia Snowe, in retrospect, was never going to deal. I'm not actually sure that would've been true if Democrats had 59 votes rather than 60 and so she didn't have the luxury of abandoning the bill without voting against it, but I think it certainly became true as this process wore on.

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Very close to 2 Amys: Ezra, your list of favorite DC restaurants was an outrage! The title suggested "in the district", but some of those places were outside. And what's up with the poor showing of Asian joints? No mention of Ethiopian food in DC? Not a single one of those amazing Korean places in Annandale?

washingtonpost.com: My 12 favorite places to eat in DC (The Internet Food Association, Jan. 13)

Ezra Klein: Three of the 12 were Asian joints! But as I said, it was "my" list of places I eat, not of the best places to eat. So, for instance, I eat fairly little meat. If I ate more meat, I'd go out to Viet Bistro more often. But as it is, I go there very rarely, so they didn't make the cut.

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Chicago, Ill.: How do you think the abortion (Stupak/Nelson) issue is going to be resolved?

Ezra Klein: With great wailing and gnashing of teeth.

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Princeton, N.J.: What specific changes would you like to see made by political scientists (and academics in general) to encourage more frequent and productive exchanges between the academy, the media, and the public? What specific changes should journalists make to the same ends?

Ezra Klein: It's hard to say. I'd like journals to open so I could access the articles. I'd like there to be some serious effort to either reach out to journalists with relevant research or start blogs that bring relevant research to the attention of everybody. I think it would make sense for them to have some Washington presence so that political journalists could call political scientists in the same way policy journalists call experts. On the journalist side, I'd like to see us, well, begin integrating political science into our work and, maybe more importantly, our thinking. We need to become more structuralist.

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Los Angeles, Calif.: My five-year-old son, who just started school in September, just asked me, "Was President Obama really born in Hawaii?"

I was a bit floored. I think that rumor has crossed the line in one for the ages and my great-great-great grandchildren are still going to know about it which is so sad and say something terrible about us right now.

Ezra Klein: That is very, very sad.

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Las Vegas, Nev.: I know I'm going against common wisdom here, but I think this has been a good week for Senate Majority Leader Reid. I never knew how important a role he played in getting then Senator Obama to challenge the Clinton machine back in Summer 2006.

I mean I never knew that he had a 100% rating from the NAACP.

Plus President Obama, Michelle Obama, Al Sharpton, Jesse Jackson, etc ... have all come out this week complimenting him. People who have really cred in our community backing him helps.

As a Black Nevadans, I think I'm more likely to support, donate and vote for Reid's re-election after this week.

Ezra Klein: My sense is that fairly few people actually dug into the context of this story, which is a shame. But as you say, the more you know about the Obama/Reid relationship, the more insane this whole controversy is.

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Indianapolis: A lot of progressives have complained that the bills being considered don't include a premium cap, yet they oppose the excise tax. This seems like an enormous disconnect to me; isn't the excise tax basically a form of a premium cap? The complaints being raised about an excise tax -- that it may cause some cost-shifting to consumers, etc. -- would still be true in the case of a cap, wouldn't they?

Ezra Klein: Yep. As it is, any cost control you can think of will have some adverse affects on some people. A premium cap will reduce benefit generosity or increase cost-sharing. Having the government set lower payment rates will lead to longer waits or less access for people in areas where providers go out of business. I'd actually support all this stuff, because I think saving money on health care is worth a certain amount of disruption. But people shouldn't fool themselves about the difficulties here.

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La Grande, Ore.: Please make predictions given your current understanding of the Health Care reform bill:

1.) In 2014, how many Americans will not have health insurance?

2.) The US currently spends about double for health care than any other country, for less coverage. How will those stats look in 2014?

Ezra Klein: In 2014, the bill won't really have started yet. That's its first year of operation, and it's not even fully operational.

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What's in it for me?: There are so many of us in precarious situations with regard to health care. I, for instance, have two full-time jobs (first job provides insurance, second job pays for the copays, coinsurance, fees, and whatever's not covered because of that "above reasonable and customary charge" clause). But now I've got a brain tumor, so goodbye to the second job and hello to crushing medical bills, bankruptcy, and desperation.

Any health-care bill that comes along isn't going to help millions of us who are in situations like these.

I'm going to leave the U.S. An organization in another country is going to help pay for my brain surgery and initial postsurgical treatment. I may not be able to come back to the U.S. until 2014, because I won't be insurable under most current insurance contracts. But it's a moot point, because I would have lost my job and my house and everything I own anyway.

It's kind of a shame that I have to leave. I've been politically active in the U.S. my whole life. And with two full-time jobs, I've definitely contributed my fair share to the tax coffers. And I'm going to miss my children and grandchildren and my lifelong friends.

But them's the breaks.

Ezra Klein: Oy.

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Chicago, Ill.: The White House has said there has been considerable progress in reconciling the two healthcare bills. Do you know, specifically, what has been agreed to?

Ezra Klein: Nope. Don't think anybody does. But I think it's pretty clear what is likely to be agreed to: They'll weaken the excise tax, increase the subsidies, nationalize the exchanges, sacrifice the employer mandate and modify the Medicaid deal.

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Clovis, N.M.: Nelson has a political problem because he cut a sweetheart deal.

To solve the political problem, you suggest everyone be given the sweetheart deal.

If everyone gets the sweetheart deal, what does that do to the CBO score, Obama's assurance of deficit neutrality, and the overall perception of the legitimacy of the legislation?

Ezra Klein: Well, it's also good policy, and it isn't my idea. But the CBO score will go up.

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Vancouver, Washington: Ezra: On a lighter note did you decide on a slow cooker yet?

Ezra Klein: Nope!

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Ithaca, N.Y.: If there was a such thing as Fantasy Congress, would you play?

Ezra Klein: Absolutely not. I spend far too much time worrying about the real Congress to have to start worrying about a fake one.

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Minneapolis, Minn.: You made an interesting statement about Americans' views on health-care reform over time; positing that support will grow once the bill is passed because (I paraphrase) "sausage sells better than sausage-making." Do you say this based on gut feel or do you have data from other legislation that supports the point?

Ezra Klein: I'm actually beginning to look through old polling on this. One problem is we've not passed anything as big as HCR in awhile. But you do see this consistently with elections: Many more people say they supported the winner after he wins. But stay tuned for a more comprehensive look at the data here.

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Bill, New York City: Hi Ezra, can you clarify two things? One, the primary care doctor shortage has been well documented. With 30 million more joining the ranks of the insured, shouldn't we expect things like how quickly we can see our doctor shortage worsen?

Two, for those who will now have to buy insurance due to the mandate, how much will the typical working class individual or family have to pay on a yearly basis after accounting for government subsidies? If you can generalize or want to be more specific, either way it is appreciated.

Ezra Klein: 1) This is why it's important to include pieces such as Sanders's amendment increasing funding and loan repayment for primary-care docs.

2) CBO did a report on this (search "CBO and premiums" on my blog and you should find it). The quick answer is that premiums go down even before subsidies go up. But because subsidies go up, and people can buy better insurance, they buy better insurance that's more expensive than they could've afforded without the subsidies but that's cheaper than it would've been without the regulations brought in by reform. Put another way, we subsidize them to buy more expensive insurance at a new, low price. Got that?

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Chapel Hill, N.C.: Hi I was recently diagnosed with a preexisting condition. I'm 19 years old and I was wondering whether "community rating" would allow me to pay the same as other 19 year olds in the individual market. If so would that occur immediately if the bill is signed in law or in 2014? I'm referring to the community rating condition of the bill. Thanks

Ezra Klein: Yep, community rating will lend the relevance of your preexisting condition. I seem to remember that this actually starts immediately for young folks, but I don't remember if young here refers to under 26 or under 18. You'll want to check it.

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Ashburn, Va.: Are there any GOP members who are participating in the reconciliation process between the House and the Senate bill? Or, have the Dems just decided that there is no point as they will vote no anyway?

Ezra Klein: No GOP members.

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Boston, Mass.: Hi Ezra, Thank you for your tireless work following the health care debate. I have a question that I haven't seen addressed anywhere, and was wondering if you could help me out.

My understanding of the legislation is that the new subsidies will only apply to people purchasing insurance in the exchange, meaning that people enrolled in employer-based health care will not begin receiving subsidies (unless their business is small enough to qualify for purchasing insurance in the exchange, or the company is hit by the free rider provision). Because only 10-15% of Americans will be enrolled in the exchanges, the $150-200 billion per year set aside in the bills will be sufficient to pay for the subsidies of everyone in the exchange. Most advocates of health care reform (myself included) hope that the exchanges will eventually expand to include a much higher percentage of the population, either through a continuing decline in employer-based health care or through future legislation to allow larger employers to participate. The taxes funding the exchange aren't directly based on the number of people participating in the exchange, so in the case that the number of people in the exchange rises dramatically, will the $150-200 billion be enough to subsidize the insurance of a much larger population in the exchange? If not, will future legislators looking to open the exchanges have to find an additional budget for increased subsidies? It seems to me that, if opening the exchanges requires Congress to find an additional $200 billion per year to pay for new subsidies, it's much less likely to happen.

Thanks!

Ben

Ezra Klein: In general, people whose employers buy them into the exchange are eligible for subsidies. So if larger employers get to come into the exchange, that doesn't actually change the subsidy mix at all.

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New Hampshire: Another vote for leaving the U.S. here. I'm close to fifty, which means American companies, worried about their health insurance costs, don't want me on the payroll, but I have sufficient language and technical skills to work abroad. Why would I stay in the U.S.? My hope is that if I spend my fifties in Europe and Africa, my native country will get a bit more humane, increase access to health care (which, for some bizarro reason, I think is important as you age) and I'll be able to come back. If not, well, you know, that American passport doesn't mean much when you're one of the arbitrarily excluded. It wouldn't be my first choice to seek citizenship elsewhere, but it is definitely my plan B.

Ezra Klein: Well, I don't know how awesome the average African health-care system is, but I imagine there is some small amount of immigration to Europe based on health-care issues.

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Scarsdale, N.Y.: How big of a margin of victory would Martha Coakley need in the Mass. special election for the story the following day to be anything but bad news for Democrats? And what do you think is the likelihood that she will achieve that margin?

Ezra Klein: I'd say 8% and above and the story is no story. But beyond that, I don't think the story matters. Holding that seat matters.

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Blacksburg, Va.: Isn't the CBO pretty new to Capital Hill?

Personally, the CBO and all its abstract projections for 2020 (god only knows what countries will have invaded by) kind of bothers me in how much power it has.

Ezra Klein: CBO was created in the ’70s.

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Laurel, Md.: This is more of a philosophical question than economics, but I'm curious about your reply. I think a major problem with politics today is the skill set needed to get elected is not the skill set needed to be a good and conscientious legislator, and very few people combine both qualities.

Your thoughts?

Ezra Klein: I think that's sort of right, as far as it goes. But I think the bigger problem is that we think of Congress in terms of individual legislators rather than parties. What individuals do is structurally determined, at this point. There are a few exceptions here for chairmen and people who control key votes, but your average backbencher is a cog in a machine.

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re: Ezra On a lighter note did you decide on a slow cooker yet? : Why get a slow-cooker? Get a Staub oval cocotte from Hill's Kitchen. More versatile ...

Ezra Klein: A "cocotte," huh? Off to Wikipedia I go ...

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Cleveland, Ohio: I'm worried about what happens with the inevitable disappearance of the 60-vote majority. I also have a hard time envisioning the minority party allowing a complete shut-down of the Senate, which to my knowledge has never occurred on the level we'd see. Do you actually foresee the Republicans having the guts to stop a 56 or 57 vote Senate?

Ezra Klein: Yep. It's not a shutdown of the Senate. It's just that nothing beyond essential business gets done. Appropriations pass, but cap-and-trade is unlikely. We take care of duties but don't affirmatively solve our problems. That sort of thing.

By Ezra Klein  |  January 14, 2010; 2:30 PM ET
 
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Next: White House and union leaders reach deal on the excise tax

Comments

On the question from Princeton, N.J.,

How about encouraging ArXiv to open their doors to quantitative papers in the social sciences? Or if not, it probably would take a pittance in resources to create a preprint server like ArXiv for social science preprints.

Imagining that someone may have already done exactly the same thing, I found the following resources:
http://web.hks.harvard.edu/publications/workingpapers/
http://polmeth.wustl.edu/workingpapers.php
http://www2.lib.udel.edu/eresources/preprints.html

Not really ArXiv, but its a start.

Posted by: zosima | January 14, 2010 3:06 PM | Report abuse

"The US currently spends about double for health care than any other country, for less coverage."

Roughly, I suppose, that's about right. However, I think it's telling to look at the National Geographic graph that Ezra posted yesterday [link at bottom] to compare the USA to Japan and the Czech Republic.

The USA spends nearly 3 times what Japan spends and about 4.5 times what the Czech Republic spends. Citizens of those countries see the doctor at least 12 times per year while people in the USA go less than 4 times. Life expectancy in the USA is only one year more than that in the Czech Republic [one really expensive year] and shorter than that in Japan by about 5.

I wanted to mention this because it highlights what a bad deal we're getting. Also, someone at a holiday party I attended claimed that we spend about 60% more than we should, which would still be bad, but grossly understates the case.

http://voices.washingtonpost.com/ezra-klein/2010/01/america_spends_way_way_way_mor.html

Posted by: bcbulger | January 14, 2010 3:56 PM | Report abuse

To clarify, we are not simply paying 100% more than other nations on health care because we are not getting what Japan or France get in return. We are getting sub-par care at an outrageous expense.

Posted by: bcbulger | January 14, 2010 4:00 PM | Report abuse

I don't think a cocotte is a substitute for a slow cooker. The advantage of the slow cooker is I can leave it cooking unattended. I would never put something in the oven and head off for work.

Posted by: cminmd1 | January 14, 2010 4:52 PM | Report abuse

"But it could be a political problem: It changes the narrative, forces the Dems to push the bill through on a rapid basis, and generally makes an already ugly process a whole lot uglier." I guess we'll see soon, if Ms. Coakley completes her amazing collapse. You're assuming that Congress will continue trying to do what it's doing, working within the constraints of a new Republican Senator showing up soon. But I imagine it will change the narrative a lot more. Some Democrats may finally "get it" that most of us out here want them to stop in their tracks. Where the alternative is running even faster before we catch them.

Posted by: MikeR4 | January 15, 2010 12:23 PM | Report abuse

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