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The five most promising cost controls in the health-care bill

It's hard to overstate how important the Congressional Budget Office (CBO) -- which makes the official judgments on how much bills cost and save -- is in Washington. But the rest of the country doesn't know what the CBO is, and it doesn't care. "Washington may live and die by the pronouncements of the Congressional Budget Office," wrote pollsters Doug Schoen and Scott Rasmussen in the Wall Street Journal, "but 81 percent of voters say it's likely [health care reform] will end up costing more than projected."

That's left Democrats in a worst-of-both-worlds situation: They've built a bill that Washington's toughest scorekeeper says will cut the deficit by more than a trillion dollars over 20 years. They're getting attacked for the taxes and Medicare reforms that save all that money. But the country doesn't believe the savings are real.

One of the problems Democrats have had is that it's very easy to understand the one thing the bill does to spend money -- purchase insurance for people who can't afford it -- and considerably harder to explain the many things it does to save money. Another is that a lot of the savings have to do with changing how medicine is practiced, which people are less familiar with than how insurance is purchased.

But the fact that the cost controls are complicated and numerous doesn't mean they're absent, or that they won't work. So here are five of the bill's best ideas, and how they're meant to work:

(1) Create a competitive insurance market: This is the bill's first, and most important, step. Right now, the insurance market's version of competition is pretty brutal. Companies compete to avoid the sickest people and sign up the healthiest people. Offering the best coverage for the lowest cost isn't much of a priority, because most consumers don't know whose coverage is best, and the ones who really do know are probably sick customers who spend their days researching this stuff.

Outlawing the bad kind of competition while enabling the good kind, which the bill does, is more than just a humanitarian measure. It's a cost control. The insurance "exchanges" imitate the market in which federal employees (including congressmen) purchase their health insurance. In the exchanges, insurance products have to be above a minimum level of comprehensiveness (no more insurance that doesn't cover anything) and their benefits have to be presented in a standard, comprehensible way. The insurers themselves can't discriminate based on preexisting conditions, will have to answer to regulators if they attempt to jack up premiums, and will be rated by their customers -- a rating that everyone else will see when shopping for their insurance.

If all goes well, consumers will be able to log onto the exchange's Web site, compare insurance plans and choose their favorite. That means insurers will have to compete for customers in a more transparent market, where shoppers have more information, and where the relationship between price and quality is more obvious. As any free-market conservative will tell you, that should drive prices down and quality up. If it doesn't, insurers will have some annoyed legislators to answer to: The bill says congressmen and their staff members need to buy their insurance from these exchanges, too.

(2) The Medicare Commission: The next cost control worth mentioning is an effort by Congress to solve the problem of, well, Congress. Medicare's cost problem is, in many ways, a political problem: Saving money means cutting someone's profits or someone's benefits, and politicians are afraid to do either.

Enter the Independent Medicare Advisory Board. Modeled off of the highly respected (but totally toothless) Medicare Payment and Advisory Commission, IMAC is a 15-person board of independent experts chosen by the president, confirmed by the Senate and empowered to cut through congressional gridlock. IMAC will write reforms that bring Medicare into like with certain spending targets. Congress can't modify these proposals, it can't filibuster these proposals, and if it wants to reject them, it needs to find another way to save the same amount of money. Making the process of passing tough reforms easier is the single most important thing you can do to make sure tough reforms actually happen.

(3) A tax on "Cadillac plans": The least popular, but most direct, cost control is the tax on expensive, employer-provided coverage, which should really be thought of as a disincentive to buy insurance plans that don't control their costs.

Today, the average employer who offers insurance pays more than 70 percent of a worker's premiums, all of it tax-free. This amounts to an annual $250 billion subsidy for private insurance for people with good jobs. But it's not just the size of the subsidy; it's how we use it that matters. Because it's only good for insurance that employers buy for their workers, people have their employers buy their health-care insurance for them. But that means individuals don't know how much their insurance really costs and don't have as much incentive to keep those costs down. Imagine the pressure for cost control if the 70 percent that employers pay were coming out of our own pockets, instead of quietly coming out of our wages.

In 2018, the proposed excise tax on so-called "Cadillac plans" slaps a 40 percent tax on every dollar spent on an insurance plan above $27,500 annually. So if your plan costs $27,600, the final $100 bucks would be taxed (technically, the insurer pays the tax, but it'll pass that onto your employer). That's a very expensive plan, but over time, that $27,500 threshold grows by inflation, usually around 3 percent) rather than health-care inflation (closer to 7 percent). So if we don't get health-care inflation down, this will hit many more plans.

But the excise tax is part of getting that inflation down. The idea isn't that people will pay this tax. It's that they, or their employers, will evade it by choosing insurance that holds its costs down more aggressively. That gives insurers who hold costs down a competitive advantage against insurers who don't, because those who don't are not only offering pricier insurance, but are also passing along a hefty tax attached to their excess spending.

(4) Medicare "bundling" programs: The most obviously illogical part of our current health-care system is that we pay doctors the way we pay car dealers: They get more money for every item they sell. But while we aren't afraid to ignore a car dealer's recommendations, we are afraid to disagree with our doctors. As you'd expect, this pushes costs higher.

The health-care bill seeds Medicare with many experiments to change this status quo, the most immediately promising of which are the "bundling" programs. Instead of getting paid for everything they do to help a diabetic, hospitals will get paid once for treating that person's diabetes and all related conditions over a certain period of time. If this leads to lower costs and doesn't harm patients, it will be expanded. That would be the beginning of the end of paying for quantity of treatment, and the beginning of paying for quality of treatment.

(5) Changing the politics of reform: Republicans and Democrats both agree that we need more cost control in the health-care system. But politicians don't like to actually cut costs, because those votes reduce benefits and make people angry. So we've played a shameful game: We passively control costs by letting people become and stay uninsured, or by letting their insurance deteriorate and cover less, because those things don't require a vote in Congress.

But because the individual mandate in the bill brings everyone into the insurance market and the subsidies for those who can't afford insurance on their own put Washington on the hook for costs, Congress will have to get serious about holding costs down in the system. The alternatives, for lawmakers, are high costs infuriating constituents who're being forced to buy something they can't afford, or yawning deficits forcing them to vote to take subsidies -- and thus health-care coverage -- away from people who currently have it. The days of letting inertia win the day and watching the system fall apart on its own are over.

Thus ends the list. There are more cost control ideas in the bill, of course. Everything from modernizing the system's IT infrastructure to amassing and disseminating research on which treatments work and which don't to penalizing hospitals with the highest rates of infection. Five is just a good round number.

The bill's basic theory is to try pretty much everything in the hopes that some of it works out. The net effect is to make reform a continuous, rather than occasional, process, with different cost cops patrolling different beats. Insurers will have to work to stay a step ahead of the excise tax because employers won't want to buy plans that trigger it. The industries that provide medical care and technologies will have to hold their costs down because they don't want to become a target for the Medicare Commission. Hospitals will need to make sure they don't spend more than their competitors because they'll lose money under bundling. And if we want to try other things -- a public option, say, or incentives for insurers to abandon fee-for-service -- the exchanges give us an actual structure where we can make changes and test reforms.

Also important is that the various elements work together. For instance, the excise tax and the exchanges have an important interaction. Right now, there's a substantial amount of inertia among employers. They've got a contract with a health insurer and they don't want to waste time soliciting new bids and trying to figure out the relatively quality of different providers every year. In the exchanges, however, changing would be trivial: You'd see the prices (with the excise tax built in), and it would be a lot easier to see if cheaper plans were providing a good consumer experience.

Same goes for IT improvements and the comparative effectiveness research: As the data is crunched, it could be fed into software that'll help doctors choose the most effective treatment based on the latest evidence -- a far cry from them mainly knowing about new evidence because drug companies have spent money publicizing it. Or take the Medicare Commission, which will use a lot of the comparative effectiveness program's data when making its decisions.

Adapted from my Newsweek column.

By Ezra Klein  |  March 22, 2010; 11:46 AM ET
Categories:  Explaining health-care reform  
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Comments

--"The bill's basic theory is to try pretty much everything in the hopes that some of it works out."--

That's a lie, Klein. The free market is where "petty much everything" is tried by hundreds of millions of people making independent decisions every day. What's going to happen now is that a very few people will take barely educated stabs at what they think will work, and the wealth and health of the nation will rise or, more likely, fall on the sheer luck of their guesses.

Posted by: msoja | March 22, 2010 12:01 PM | Report abuse

1. There isn't really going to be any competition. Insurers have to offer the same coverage to everyone and can't raise prices (unless regulators let everyone raise prices). Under those conditions, they're all going to cost essentially the same.

2. Any attempt by one Congress to bind another will be struck down as unconstitutional.

3. We all know which entities have the Cadillac plans, and who in Congress listens to them.

4. This sounds like a good idea, but I wonder if hospitals will find ways to game the pricing so that they end up getting paid as much as they do now.

Posted by: tomtildrum | March 22, 2010 12:05 PM | Report abuse

This "sham" will do nothing to curb costs and reduce premiums. This is just payback to the entitlement groupies that voted Obama into office. The feds control Medicare and look what has happened to that program. And, will there be actual cuts to Medicare? And, will there be taxes on high value plans in 2018? No, on both counts. We have been had! We got "stupaked!"

visit: http://eclecticramblings.wordpress.com

Posted by: my4653 | March 22, 2010 12:10 PM | Report abuse

Why do I think that with the private health-care market locked in for the foreseeable future by this bill that cost control won't be achieved through cutting into its revenue but will be achieved by cutting services to consumers and making us pay more for those services?

A blue-ribbon Medicare commission will look after whose interests, exactly? Ours?

And who's regulating the exchanges? The states? A federal government that's shown how comfortable is with insurers and providers?

And lots of experiments and pilot projects, studies that will yield exactly what, and when? Taxes that will force us (by evading them) to make insurers more competitive? What?

Here's a tip: "Complicated and numerous" (and provisional) attempts at cost control means diffuse, hard to explain, and hard to make work. We could have done this a lot easier and more directly either through agitating for single payer or through durectly regulating the private market in health care like a utility, a la the Dutch and Swiss model. We chose not to. Now we've constructed an unproven Rube Goldberg contraption with many moving parts that we hope will work. I hope so too. But it's a dumb way of going about it when there's a proven model or models out there already.

Posted by: redscott | March 22, 2010 12:16 PM | Report abuse

"Enter the Independent Medicare Advisory Board. Modeled off of the highly respected (but totally toothless) Medicare Payment and Advisory Commission, IMAC is a 15-person board of independent experts chosen by the president, confirmed by the Senate and empowered to cut through congressional gridlock. "

Anything which requires Senate confirmation can't possibly cut through Congressional gridlock. Whose dumb idea was that?

Posted by: redwards95 | March 22, 2010 12:19 PM | Report abuse

let me take these one by one and tell you why I think they're doomed to fail to control costs.

1-competitive market. This is all well and good as long as the healthy are in the market with the sick. With an ever weakening mandate and costs that continue to rise to widen the disparity I'm worried too many will stay away and pay the penalty and come in when they get sick (we also need to ensure there are strict rules of open enrollment included similar to employer markets and medicare)

2-Medicare Commission--if we even assume that this will have any affect at all on Medicare then in turn doctors and hospitals could very well turn to private insurers to cost-shift their expenses. This will raise costs on the private market (including the exchange) and as long as insurers adhere to the weaker MLR then costs will continue to go up with little to stop it.

3-tax on Cadillac plans-- this would have had to me the strongest affect if it wasn't adjusted in the reconciliation package. Now its pushed off (if approved by the Senate) to 2018 and at least one liberal (Lawrence O'Donnell) think it'll never happen. Sure it'll take 60 votes to get it out but you don't think legislators will absolutely run on decreasing your tax burden? They do it now all the time.

4-Medicare bundling--this already happens many times in private insurance plans so I honestly don't see much savings coming from that. Also if Medicare pays less and docs and hospitals want more $$$ they'll try to force insurers to higher prices to keep them going. (see examples of MA pushback on capitation)

5-changing politics of reform--ya good chance of that happening. Liberals and progressives are already screaming about the mandate (as are idiotic Republicans) and states are already running on repealing certain aspects of it. I'd like to believe this could happen but I've seen how polarized this can be.


The best thing could be if we see everyone getting covered and see uncompensated care costs go down that it could be funneled into other areas (as long as it doesn't remain in one groups pockets/profits.)

Posted by: visionbrkr | March 22, 2010 12:22 PM | Report abuse

Msoja: "What's going to happen now is that a very few people will take barely educated stabs at what they think will work, and the wealth and health of the nation will rise or, more likely, fall on the sheer luck of their guesses."

Sort of like happens in every other industrialized democracy, and just look at the terrible health outcomes in those countries!

Oh wait... they have better health outcomes than us and spend less money.

But America is the best! That can't be right! This is socialized medicine, and socialized medicine is terrible! Those other countries' statistics are meaningless!

Posted by: cdunc123 | March 22, 2010 12:35 PM | Report abuse

Oops, somehow the last half of my comment got deleted -- the half that made clear the final paragraph of my previous post was sarcastic.

Posted by: cdunc123 | March 22, 2010 12:38 PM | Report abuse

@msoja, if you have employer based coverage, how many choices do you really have- can you choose a non-profit that delivers evidence-based team care, or a for-profit fee-for-service (like, the sicker you are, the more money they make off of your insurance company)? And most likely you'll notice that premiums have gone up, probably more than the average increase in wages of your workplace. Increases the could've gone into your pocket if there were true cost control.

If you don't have based employer based coverage, you probably have even fewer choices.

And you don't have any insurance, I suppose you could choose which ER you go to when you need- oh- you won't have to, cuz this bill will require and subsidize if needed a plan for you.

Posted by: Lonepine | March 22, 2010 12:39 PM | Report abuse

A great post from Ezra,

This reform package really has so many good aspects (in contrast to almost everything that congress seems capable of doing) that people on the left and right seem unable to comprehend or believe it.

The medicare commission is so much stronger than anything I would have ever thought could pass congress. It is a really great development - with the comparative effectiveness research data and data from some of the bundling and payment reform experiments it could really stand a chance of changing how medicine is remunerated (and thus practiced!) in the United States (the private market will undoubtably follow medicare's model more or less wholesale)

This bill, despite people's wide misunderstanding of it, could mean the birth of an actual healthcare SYSTEM in the United States, rather than the fee for service cluster**** that is currently bankrupting the richest nation in the world and killing it's citizens.

Posted by: lazza11 | March 22, 2010 12:51 PM | Report abuse

Mr. Klein--

According to Atul Gawande's article in last December's New Yorker, the real opportunities for cost control are squirreled away in a little discussed section of the bill that provides for pilot programs for cost control and improvement of delivery. Your thoughts on this?

Posted by: BioProf | March 22, 2010 12:52 PM | Report abuse

BioProf - Ezra addresses that point in #4 above:

"The health-care bill seeds Medicare with many experiments to change this status quo, the most immediately promising of which are the "bundling" programs."

The medicare commission can then take the data that is generated by these pilots and send it to congress for a filibuster proof up or down vote - and best of all if they want to reject the advice they need to find another way to save the money.

All in all *incredibly* good news that exponentially increases the chances of some of the incredibly important payment reforms that Dr Gawande is talking about making it into law.

Posted by: lazza11 | March 22, 2010 1:03 PM | Report abuse

How the insurance Exchanges lower premiums:

Ezra, here's something from the important actuarial value measurement report you gave us:

"One analysis, prepared under contract by the Small Business Administration (SBA)Office of Advocacy, found that insurers’ administrative expenses for health insurance sponsored by small employers—"small group coverage"— amounted to 33%-37% of claims; for large companies’ self-insured plans, administrative expenses amounted to 5%-11% of claims. For small group coverage, the cost of commissions were found to make up 4%-11% of premiums, taxes and fees 2-3%, general expenses 10%-11%, and profits 4%-5% of premiums."

Individual health insurance agents in your native California earn 15%-20% first-year commissions, and most individuals don't stay in their plan very long. Because the Exchange eliminates the need for insurance agents, those costs (4%-11% in the small group market and even more in the individual insurance market) are all but eliminated (the fee to go onto the Exchange being a much, much smaller cost).

But, yeah, underwriting is a major cost, and with it severely restricted, average premiums will go down for an identical policy. With the smoker rating, I'm not sure how that is going to work. It's not like geographic region, family structure, and age, where you can verify by a database. Which is why Massachusetts doesn't have a smoker rating.

Posted by: moronjim | March 22, 2010 1:06 PM | Report abuse

"But the country doesn't believe the savings are real."

The country doesn't believe that Congress will cut $500 billion out of Medicare. You want to make a believer out of the country? Put the cuts into the reconciliation fix. Right now.

Posted by: bgmma50 | March 22, 2010 1:09 PM | Report abuse

The cutting of 500 billion from medicare is largely in the form of clamping down on medicare advantage - a bush era unregulated giveaway to private insurers. There is really no reason that privately administered medicare should be paid 25% more than the public version! The democrats have shown a willingness to clamp down on this sort of abuse (see the student loan reforms passed at the same time as HCR). In return seniors get the much more useful closure of the "donut hole"

Posted by: lazza11 | March 22, 2010 1:19 PM | Report abuse

(Oops - sorry more like 14% more for advantage... I knew I should have checked my numbers before posting)

Posted by: lazza11 | March 22, 2010 1:21 PM | Report abuse

The passing of this bill is an important step forward. I am only sorry that there was not a "public option" component. We already have three models from which we could have gone forward to fulfill the needs of the American Public - TriCare for Life, Medicare, and the insurance given to the members of Congress.

Posted by: bobbid | March 22, 2010 1:25 PM | Report abuse

"The democrats have shown a willingness to clamp down on this sort of abuse (see the student loan reforms passed at the same time as HCR)."

I'd like to see the Democrats actually put the savings into the reconciliation fix as opposed to creating yet another toothless commission. Better yet, they could apologize to Jim Bunning and eliminate the dox fix they just passed.

The student loan reforms are indicative of nothing as regards the spine of Congressional Democrats. Quite the contrary.

Posted by: bgmma50 | March 22, 2010 1:46 PM | Report abuse

"If all goes well, consumers will be able to log onto the exchange's Web site, compare insurance plans and choose their favorite. That means insurers will have to compete for customers in a more transparent market, where shoppers have more information, and where the relationship between price and quality is more obvious."

You have obviously never purchased individual health insurance, or you would know that you can compare and purchase hundreds of plans online at ehealthinsurance.com

Posted by: bgmma50 | March 22, 2010 1:49 PM | Report abuse

So Ezra's first supposed cost control is based on this statement: "It's a cost control. The insurance "exchanges" imitate the market in which federal employees (including congressmen) purchase their health insurance," which conveniently ignores the fact that premiums in the FEHBP are actually increasing even faster than premiums in the private market.

Yes, that is right, Ezra is claiming that this is a cost control by saying it is like a program with faster-rising costs than the current market.

The intellectual dishonesty is stunning.

Posted by: ab13 | March 22, 2010 1:50 PM | Report abuse

" The insurers themselves can't discriminate based on preexisting conditions, will have to answer to regulators if they attempt to jack up premiums,.."

I'm curious, who will the "regulators" be? It's my impression that there will be no Federal regulation of health insurance premiums, just coverage. Can someone clarify?

Posted by: Beagle1 | March 22, 2010 2:06 PM | Report abuse

The cost savings measures in the HCR look to be an excellent start. I'm a little bit suspicious of the changes that were made in the excise tax to appease unions. The fact that they changed the growth of the threshold to inflation rather than inflation+some percentage, makes it more likely that the excise tax will be too large in the future. Increasing the likelihood that Congress revisits the tax and makes it weaker like what happened with the Republican's Sustainable Growth Rate. The fact that SGR was too large and effective rather than too small and ineffective is what ultimately lead to its failure.

@bgmma50:
Even if we took you literally, since Medicare outlays for the year are less than $500 B, there is no way that $500 B can be cut from Medicare "right now". The cuts in Medicare that were scored by CBO are legally required by the bill. There is no additional act that Congress can take to enforce these changes in the future.

Posted by: zosima | March 22, 2010 2:10 PM | Report abuse

The individual mandate and the iInsurance exchanges.

These will be the Republicans' and Conservatives' first attacks against reform, getting the mandate declared unconstitutional, followed by individual states opting themselves out of the exchanges on the claim of states' rights.

The Democrats' and Liberals' defense of these challenges will have to survive an decidedly unfriendly conservative Supreme Court.

Losing one or both could undo all the rest. The first battle has been won, but the war will sadly continue for a long, long time.

Posted by: tomcammarata | March 22, 2010 2:10 PM | Report abuse

I have heard a lot of bull in my day but this is the topper.

Posted by: charlie448 | March 22, 2010 2:59 PM | Report abuse

Now that we have this and the United States will no longer be on the road to bankruptcy because of its health care system, the government can concentrate on doing what is most likley going to happen...bankrupting the middle class who is going to end up paying for this monstrosity.

Posted by: ironpenguin | March 22, 2010 3:07 PM | Report abuse

I am not encouraged given the amount of financial disasters administered by the federal government... medicare, social security, fannie mae and freddie mac- which led to the economic/bank crisis- so why does anyone think this will work? I hope it does, but the track record isn't good. If I were a lender and this was the track record a client submitted to me, I laugh them all the way out the door.. oh wait, I am a "lender" I am one of the taxpayers who will be underwriting this .. I have a pretty decent health care plan (although not as good as the union who manages to be exempt for years) and I have a pretty decent job - a typcial W2 wage earner who has precious few places to protect my money from the grubby hands of governement who wants to redistribute it..
If we are to pay health care for all,why don't we insist that people take responsibility for their health.. lose weight, take care with the foods they eat, exercise, etc. afterall the American Cancer Society says that 2/3 of all cancers in the US are lifestyle cancers.. meaning our life style leads to disease. So as a taxpayer and underwriter of this massive policy, why can't we insist on some personal responsibility for health? And by the way, just how much money are we going to spend on neonatal instensive care?? since there is no "cap" under this policy.. does that mean we will spend millions and millions per baby? why haven't we, the American people, been allowed to have a meaningful national dialog about what this means to us- as a nation and as individuals. I for one will never ever again in my life vote for Democratic. I have changed my voter registration from Democrat to independent. I will work very hard to unseat these people.

Posted by: pamm718yahoocom | March 22, 2010 3:12 PM | Report abuse

Republicans claim that this bill is a fiscal Frankenstein that costs $940 Billion. But these same people thought nothing of the cost to the government and to the people of two Bush tax cuts that cost us billions and two wars, one of which is illegal in excess of two trillion dollars never once having a dollar of it in the budget. They used supplementals to keep it out of the mainstream discussion. We continue to have to pay for these wars and the rescue of the financial system as a result of no controls by the Bush Regime and allowing banks to violate all of the rules. Hypocrisy is the nickname of the Republican party.

Posted by: ronjeske | March 22, 2010 3:32 PM | Report abuse

Hey Ezra, if Congress kept its snout out of health care to begin with, we wouldn't be in the mess we're in now. See, Congress creates a problem, (requiring hospitals to treat anyone with an emergency, real or imagined without compensation) (prohibiting insurance companies from selling across state lines) (reducing the number of hospital beds available in order to cut costs) (No tort reform) then bemoans the problem, (emergency rooms shutting down) (lack of competition among insurance companies) (Hospitals shutting down) (doctors driven out of business or forced to pay exorbitant premiums). Oh no, now emergency rooms are shutting down, there's a lack of hospital facilities, medical care costs are sky rocketing because people have to pay for frivolous law suits and illegal residents, who drain the medical system by using emergency rooms as their personal health care system. Solution? Congress declares an emergency that must and can only be solved by, they claim, more government involvement, thus creating more problems and the need for more government "solutions."

Posted by: WriterDude | March 22, 2010 3:41 PM | Report abuse

Here's the easiest solution. The government slaps on price/premium freeze, retroactive to say 02/01/2009. Any insurance company that fails is taken over by the government, ala GM. The price controls this purports to institute are a joke, they are no going to cut the Docs for $210B or so, and no cadillac taxes ever...the rest of the cuts are "budget leakage".

Posted by: alantich2000 | March 22, 2010 3:56 PM | Report abuse

Cost Control is the biggest lie in the Obamacare debate!! Name ONE program that the Government runs, within budget, or better than private enterprise!

The answer as always is NONE, NONE, and finally NONE!!!

There are only deficit cost adders in the Bill, NOT cost control!

Posted by: morphy | March 22, 2010 4:00 PM | Report abuse

Klein is such a joke. Everybody knows that Social Security, Amtrak, the Post Office, Medicare & Medicaid, Fannie & Freddie, are all broke. Now this columnists gets his Marching Orders to Bullcrapp Americans into thinking it will work. The Repeal will be easy as Millions are harassed by the IRS or being threatened with Jail. Yes, the People wanted HealthCare Reform but through privatization, not a Communist revolution. The Obama powerplay is based on the Marxist belief that you can justify Big Government through convincing the people that both God, and personal rights, do not exist. The greatness of America is that we have permission to believe in ourselves and the God who made us. As the economic boot of Socialism presses in on the peoples throats they will revisit the concept of Hope and Change under a Marxist dictator.

Posted by: givenallthings | March 22, 2010 4:13 PM | Report abuse

Ezra stop pretending you are a Certified Public Accountant until you know the answers to and publish them as an addendum to this article. All you do now is obviscate the horrendous truth. WHO AND HOW WILL WE PAY FOR OUR DEBTS???

1. What will be the amount of unfunded liabilities assumed with the Presidential signature? The number is north of $20
TRILLION or roughly $70,000 for every man woman & child in the USA.
2. What will be the total unfunded liabilities of the United States after the signing of the bill? THE NUMBER IS NORTH OF $60 TRILLION.
3. What is the national debt? The number is north of $12 TRILLION.
4. What will the National Debt be after the current deficit spending ceases? The number will be north of $20 Trillion.

Now Ezra tell your readers how the people of this country are going to pay all of the $100 trillion down in the current generation.

You don't think it can be paid down in this generation??

HOW MANY GENERATIONS AND HOW
MUCH OF AN INCREASE IN TAXES WILL IT TAKE?

WHO AND HOW WILL WE PAY FOR OUR DEBTS???

Posted by: PRRWRITER | March 22, 2010 4:16 PM | Report abuse

I believe the Cadillac health care plans will be scaled back, causing insurance premiums to decrease. But the offset to that will be a corresponding decrease in benefits that will necessarily need to accompany the decreased revenues. Also, a major cost that has not been factored in (and is not the sole result of the health care legislation), is that as America goes deeper and deeper in debt, the credit rating of the Federal Government is likely to be lowered. If/when this happens, we will be forced to pay more for any money that the Government borrows. Finally, any money that is sucked out of Medicare to pay for the health care bill, will need to be replaced at some point, unless the overall plan is to phase out Medicare when it becomes insolvent. Any replacement costs were not included in the OMB "cost" of the health care bill.

Posted by: eucag | March 22, 2010 4:21 PM | Report abuse

All of your points that will "save money" are the exact reasons I WILL NOT HIRE MORE EMPLOYEES. ALL of "the savings" will increase my costs exponentially. Sh-t rolls downhill.

Posted by: IQ168 | March 22, 2010 4:28 PM | Report abuse

Ezra Klein doesn't know a thing about cost control. If he thinks this unconstitutional monstrosity will control the costs of anything, he's more gullible than stupid Stupak.

Posted by: steve_tsouloufis | March 22, 2010 4:30 PM | Report abuse

Hey msoja, I think what you meant to say is:

"The free market is where "petty much everything that makes more money for the stockholders" is tried by the boards of large corporations making independent decisions every day."

The difference is that now we'll be trying things that help people and help the country.

Posted by: robmck@gmail.com | March 22, 2010 4:35 PM | Report abuse

@IQ168
You're not going to hire any more employees because there will be a tax on a health plan that costs more than $27.5k? Seriously? So you're saying that ALL of your employees have plans that cost that much? Wow, you're getting ripped off. You must not be a very good business man.

Posted by: robmck@gmail.com | March 22, 2010 4:40 PM | Report abuse

There will be the same numbers of doctors, nurses, and hospitals providing the same amount of health care that is being provided now spread out over another 32 million people. We will pay more for the same amount of health care we are getting now and the extra money will end up in insurance company and government pockets. This bill is not about health care. It's about subjugation and spreading the wealth around.

Posted by: websmith1 | March 22, 2010 4:44 PM | Report abuse

I still say: why are we listening to this person? Have things gotten so bad that we are not supposed to notice that he has an agenda? Don't believe your eyes....

Posted by: SueR1 | March 22, 2010 4:55 PM | Report abuse

Klien is an idiot.
Point 1) -Competition. What is good vs. bad competition and who decides? Competition is easy - to lower costs you don't find any sick people. That growth on your neck? dont worry about it. The dead don't give unfavorable ratings.
Point 4) - Bundling. How much service do you think you'll get from a prostitute once you pay her?
This guy is playing Jr High debate club and his arguments don't measure up.

Posted by: SneakyJimmy | March 22, 2010 4:58 PM | Report abuse

Ezra, generally, I agree with most of your comments, however, you are making a huge leap when you write that Americans don't believe that the health care reform will save money. I think most Americans are not fooled by the transparent nay-saying of the Republicans.

Or, put another way, the costs of getting insurance have skyrocketed. Doing nothing will not bring costs down; or, as Wayne Gretzky famously said you miss 100% of the shots you don't take.

Posted by: Reesh | March 22, 2010 5:34 PM | Report abuse

1. The way I see it, the Republican Party will point the finger of blame at the Democratic Party if anything goes wrong.
2. We all know that there will be many things that will have to be ironed out before they can be put to use.
3. If the Health plan goes into effect as has been planned, the Republicans will be held out in the cold, wondering why didn't they join in the fray to get the Health plan going.
4. But I can see the Republicans already, trying to make themselves out to be the scapegoat. when in reality, they are as much to blame for their failure to join in and iron out a health pan in the beginning that will cover all of our problems.
5. Unfortunately, the Republicans will find out that for not helping to produce a healthcare plan that would have an impact on health care. In other words, making insurance more affordable to everyone not just a select few. Making sure that everyone pays their own medical bills or a at least a portion there of. Making sure that insurance companies do not raise their rates at their own discretion but to keep them at a low rate so anyone can get insurance and be assured that they will be taken care of medically.
6. Republicans will find that they will lose more in December than they will gain. More Senate seats will become Democratic and more Representatives in the House will themselves out of an office and on the streets just like the people already out there. They will finally know what it is like to be unemployed.
7. Republicans are no longer the Republicans of the Party that helped to Elect President Lincoln in 1860.

Posted by: richardcolonel | March 22, 2010 6:12 PM | Report abuse

Our president has made many promises. A cut of $2500 per family for health insurance, for one. When might we look for that?
As for the CBO being "Washington's toughest scorekeeper," it can only count what's presented, not guess at what is yet to come in Medicare and Medicare Advantage cuts. This is wishful thinking, with no regard for the political firestorm that will result. Killing any "entitlement" is political suicide.

Posted by: Trucker49 | March 22, 2010 6:13 PM | Report abuse

WORDS> WORDS> WORDS and all in a vaccumn without a thought to the environment we are in.
1. 20% unemployed and under employed
2. 30 million legal & illegal immigrants,
health care covered by our tax dollars
3. Inflation in Medical Care AND Energy
ignored; Oil has doubled in the last YR
4. National Debt and unfunded liabilities
a. $42 trillion 4 years ago and
projected to be $100 trillion 2011
b. Social Security flipped from a cash
generator to a cash consumer this yr

WHO IS GOING TO PAY FOR THIS AND HOW??

1. CONFISCATE THE ENTIRE WEALTH (ASSETS) OF THE FORBES 400 RICHEST AND YOU WILL NOT GET $2 TRILLION.
2. CORPORATIONS DO NOT PAY TAXES; THEIR CUSTOMERS DO. The taxes are built into the selling prices . No profits for the shareholders (your IRA??) and the shareholders leave as the corporation goes broke.

Posted by: PRRWRITER | March 22, 2010 6:55 PM | Report abuse

richardcolonel wrote "Republicans are no longer the Republicans of the Party that helped to Elect President Lincoln in 1860."

Of course they are not, LBJ's signing of the 1964 Civil Rights Act changed our political scenario forever in a tectonic way. Right thinking republicans started migrating to the democratic party and southern democrats found their red necked heaven in the republican party. The rest is history.

Posted by: Franktheliberal | March 22, 2010 7:30 PM | Report abuse

Everyone will be required to have insurance? Try going into Camden or Newark N.J. and tell that to the brothers who live there. They'll laugh at you if you're lucky. If they get shot or sick they'll just go to the hospital. What are you gonna do arrest them? Ha-ha.

Posted by: think11 | March 22, 2010 7:50 PM | Report abuse

Ezra, where is the #6) on "...the basic theory is to try pretty much everything in the hopes that some of it works out"? Where are the aggressive tort reform limitations in "The ObamaCluster Bill” imposed on the Dums best friends, the ambulance-chasing scumbag tort lawyers? Why is that not on your list Ezra?

Hmmm, I guess the anti-American unholy trinity of Obama, Pelosi and Reid just let it slip their mind. Alternatively, is it because they are, as the socialist party is with everything, in the hip pockets of those bums. The soft costs on tort cases is astronomical, but no mention in ObamaCareCommieCluster. No Ezra, I’m sorry son but the basic theory is NOT to try everything. Only to impose socialism on 1/6 of the U.S. economy , use healthcare control as a backdoor pass into all other industry control, divest us of our freedoms and ignore the U.S. Constitution.

Well, then again, maybe that is trying everything.

Posted by: dlgallagher1 | March 22, 2010 8:10 PM | Report abuse

I can't wait for the 3,000% reduction in my health insurance premiums this genius President promised. Gee, I wonder if that will be available under ObamaClusterCare in all "57" states.

Also, will "corpsssssman" be able to take advantage of that also Mr. O?

After her husband signs his socialist healthcare bill it will probably be the 2nd time Michelle Obama is "...proud of her country".

Posted by: dlgallagher1 | March 22, 2010 8:22 PM | Report abuse

Mr. Klein your apologia of this backroom manipulated and fraudulently concocted healthcare reform sounds more like the dialogue of a bunch of pot smoking leftist students waxing on about how great things will be in the society they will create when they "grow up". You have no concept of insurance so pretend this a better version of it. Insurance involves underwriting and pricing to risk. This plan is merely a huge and ultimately destructive social program pretending to reduce costs as it adds 30 million people to a healthcare system already short of doctors and qualified healthcare providers. By definition it must cost more since there is no underwriting and pricing to risk; it must ration healthcare for all; it must continue to tax more people and businesses driving many out of business costing jobs of people who actually work in society.You have never had to create jobs,pay overhead and keep people employed by contolling expenses and making enough profit to grow a business. The people who avoid work now and have children by multiple non-supporting fathers will add to these roles. When Obama and the Democrats pass legislation to bring illegal immigrants into citizen status we will add millions more to this healthcare debacle and there is now way this will reduce future debt. Of course we know Obama and the Democrats expect these people to vote for them. The CBO can only score what Congress asks them to score and Congress has not told the truth on this monstrous bill for the last year. This is an unmitigated disaster looming in our future and you try to put lipstick on this pig. I believe sir you should identify yourself as a socialist progressive or a fool behind the title of journalist.

Posted by: mrtro | March 22, 2010 8:25 PM | Report abuse

Did David Axelrod wrote this "analysis", or was it the other David?

Ezra is nothing but a DNC mouthpiece who uses a somewhat credible (?) outlet like WaPo to spread his BS!

Posted by: darkskin1977 | March 22, 2010 8:57 PM | Report abuse

It is always good to control the bill in our projects, but reality is bigger than dream.
We must create 100% of employment and in result we will have money to pay medical bills.
Our transportation system is relic from previous century and we are trying to solve this problems by yesterday solutions.
Our power plants are losing more than 80% of energy-heat energy in vain.
Our green directions-solar cells, wind, nuclear, biofuel are disasters as for economy as for environment.
In climate change we follow scientists which advised Al Gore. Their explanation of reason for climate change are not scientific.
Good analysis of these directions could create 100% of employment and therefore insurance, make USA, Canada and Mexico energy independent and fight climate change with only this three countries. (North America is only one continent between Atlantic and Pacific oceans and influent climate from France to Japan.
Xlibris.com "Economy and climate change or KGB agent" January 2010.

Posted by: mioffe | March 22, 2010 10:47 PM | Report abuse

You dude..

Perhaps you had better brush up on the CBO.

Their forecasts on the Obamacare BILL are as only as good as the information they receive from the Senate and the House.

There is no mention of the 250-300 Billion dollars that will be placed into another Bill to pay the doctor's for reduction in payments from Medicare.

You mention Insurance more Competitive. The best way for this would have been to make all insurance companies able to sell across ALL state LINES.

There was no mention of any TORT REFORM to lower the insurance fees of doctor's and hospitals.. THE DEMS and REPUKS would have put to many of their friends out of a job.

There is no SUCH WORD AS COST CONTAINMENT in any department of the Government, the House, the Senate and in the White House.

Look at Freddie, Fannie, Federal Reserve System, VA, fraud in Medicare and Medicaid, Post Office and everything else the government does.

So does anyone really expect that the government will cut cost in medical facilities.

Posted by: miller515501 | March 22, 2010 11:25 PM | Report abuse

If this is such a good idea, why has congress exempted themselves?

Posted by: rappo12447 | March 23, 2010 7:07 AM | Report abuse

Day 1 after signing Healthcare Reform Bill, Senate amends to exclude Congress and their employees from having to participate in the exchanges we non-elites will be subject to. Hmmm, are we now adding and subtracting to make it the bill they really want??

Posted by: vicki10 | March 24, 2010 3:26 PM | Report abuse

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