Outlook: 'The Ghosts of Clintoncare'

Ezra Klein
Washington Post Blogger
Monday, July 27, 2009 11:00 AM

Washington Post blogger Ezra Klein was online Monday, July 27, at 11 a.m. ET to discuss his Outlook article titled "The Ghosts of Clintoncare."

"Clinton's big push for reform came in a soaring 1993 speech before a joint session of Congress, in which he offered painstaking details of his plans; Obama made his argument to the nation at a news conference last week, addressing concerns more than specifying proposals. Obama's reluctance to follow Clinton's example is understandable: Few legislative failures have been as catastrophic as Clinton's on health-care reform. Yet the ghosts of the early 1990s still hover over today's debates."

Ezra Klein reports on domestic and economic policy for The Washington Post. He blogs at Ezra Klein.


Arlington, Va.: Great column yesterday.

Bill Clinton may not have been able to pass health-care reform during his administration, but as you highlight in your column, in many ways the past decade and a half have vindicated his ideas on a policy level.

Any chance that Obama will enlist Bill Clinton to advocate for health-care reform?

As a side note, watching the process unfold in the Senate the past few months has been especially frustrating. I hate to throw around the word "corrupt" and "purchased" legislation, but it sure seems like the members of the Senate Finance Committee -- Democrat and Republican -- are more concerned about protecting the business interests of some campaign donors than protecting the health of their constituents. Very disheartening to witness.

washingtonpost.com: The Ghosts of Clintoncare (Post, July 26)

Ezra Klein: Zero chance. Clinton's involvement would be a huge distraction. And whether or not Clinton did have some good policy ideas, he's generally remembered as a failure at health-care reform: Obama wants nothing to do with that legacy.


Aguanga, Calif.: Do you think this time around, Hillary Clinton has been completely locked out of the health-care debate?

Do you also wonder about her lingering ghosts, relating to her personal trials with health-care reform?

Ezra Klein: Yep. As Secretary of State, though, she doesn't have a natural role in the health-care reform debate. You don't send the Secretary of Health and Human Services to resolve tensions between India and Pakistan and you don't send the Secretary of State to negotiate out Medicare reforms.

If Clinton wanted a real role in health-care reform, she could have stayed in the Senate, where she'd undoubtedly have been one of the most important voices in the debate this year.


Babson Park, Fla.: Medicare is already cutting care to seniors. Does anyone know this? No payment for vaccinations are permitted. I had a friend with a puncture injury by a rusty nail, but Medicare refused payment for a tetanus shot. Is this preventive care or not? Medicare refused payment for a PSA test on an elderly man I know. Is this prevention or not? We have the best health care in the world. The issue is not care, but government waste and management. How to make the government more responsible is the question; fire all the bureaucrats and impose term limits for Congress. Why make things worse with so-called health-care reform? Health care is the best in the world, but how do we keep insurance companies from raising rates beyond affordability and disallowing payments for needed care?

Ezra Klein: No. We don't have the best health care in the world. Not on any broad measure or metric. We don't have the most cost effective health care in the world. We don't have the best outcomes in the world. We can't even manage to give everyone access to health care.

That said, there are certain diseases, like breast cancer, that we are uniquely good at treating. But then we lag on diseases like diabetes. It's a mixed bag. And it's a mixed bag that we are spending twice as much as most other countries on. So it's important to say this clearly: We have a very, even uniquely, bad health-care system. Not for every individual. But in the aggregate. As a country, we spend far too much and get much too little.

If people are interested in the evidence on this score, T.R. Reid's new book

The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care

is an extremely good, and extremely readable, explanation of how our system compares to those of other countries.


New York: Ezra, thanks for such an informative article. I left a job a few years ago to launch my own business, and consequently lost my health- care plan. The plan I have now is expensive and doesn't cover drugs, and I had to give up one of my favorite doctors. So with reform on the horizon, the issue of portability was important to me. But it doesn't seem to be part of the discussion. So, say you lose your job under a 'reformed' health-care system. You still lose your insurance, and have to go out and buy your own policy or pay a fine. The new insurer will have to overlook pre-existing conditions, which is good, and the policy may be a tad cheaper than an 'unreformed' one, though you may qualify for government assistance to pay for it. But aside from these changes, aren't we still talking about a system where unemployed people still face paying for coverage in an overpriced market?

Ezra Klein: It will be cheaper than it is now, to be sure. The Health Insurance Exchanges will give you bargaining power. New regulations will limit the behavior of the more aggressive and mendacious insurance providers. The subsidies will help with affordability.

But broadly speaking, you're right: If you lose your job, your insurance is likely to change. And that's a pity. We should make the Health insurance Exchange national and open to everyone. That way, if someone buys in while they're employed by, say, the Schmashington Schmost, and your employers closes because no one bus Shmewschmapers anymore, you can keep the same insurance arrangements you had before, as you'll have gotten them through the Exchange, not through your employer.


Toronto, Canada: How much of the difficulty of passing health-care reform is as a result of special interests and how much is due to American culture, i.e. more of an "every man for himself" versus a sentiment of the common good (which ironically has produced cheaper, better healthcare for everyone in other industrialized countries)?

Ezra Klein: Actually, I think the biggest problem is with our political system. What if you only needed 50 votes in the Senate, not 60? That would give Democrats a 10-vote margin of error. Success wouldn't be assured, but it would be overwhelmingly likely. What if there weren't strong committees, and there was more party discipline? What if, in other words, our system was more like the average European system?

People often say our culture is conservative. Maybe. But it could also be that our political system is conservative, in that it's biased towards the status quo, and our culture adjusts itself to that reality. So we tell ourselves we don't have universal health care like the Europeans do because we have a different "culture." Because we chose that outcome. But maybe it's just harder to get it done here. After all, a lot of presidents have been elected with universal health care as one of their campaign promises. Medicare and Social Security are wildly popular programs. It's not like our intrinsic individualism has done anything to dent their popularity.

My hunch is that if you could somehow pass a good health-care reform bill, the resulting system would end up being quite popular.


Charlottesville, Va.: Peggy Noonan had a column over the weekend listing three points that damage support of health-care reform. The first one seemed a bit odd -- that doctors sometimes undercharge patients who are strapped financially. Is there any evidence out there supporting or debunking this? Any comments on the article overall?

Common Sense May Sink ObamaCare (Wall Street Journal, July 25)

Ezra Klein: Didn't see her article, but it's actually the opposite: Doctors overcharge patients who are strapped financially.

This is actually sort of intuitive. A piece of fruit at a good grocery store is pretty cheap. A piece of fruit at a corner bodega is often not. That's because Safeway negotiate large discounts on behalf of their customers while the bodega doesn't. Similarly, people with insurance -- be it Medicare or a large employer's plan -- have negotiated discounts. But people with bad insurance, or no insurance, don't. And so they end up paying a lot more.


Tallahassee, Fla.: What makes Obama's plan superior to a voucher-based system? It seems like the right would be much happier with that compromise.

Ezra Klein: I think that in a more sensible polity, we would compromise on a voucher system. Something like what Ezekiel Emanuel has developed. But we don't live in that polity. And the right has never come to embrace that compromise. So, for now, it's a non-starter.


Fairfax, Va.: CBO says this MedPAC idea or whatever the board of medical experts is called only saves $2 billion. Where else is Congress and the administration going to find additional savings?

Ezra Klein: That's $2 billion in the very short-term (between 2015, when it starts, and 2019). Long-term, it could do quite a bit more. As for where else we'll get the savings, it's hard to say. MedPAC could help. There could be efficiencies in the new system. Comparative effectiveness and health IT could work together to cut overtreatment. Changing the employer tax exclusion could reduce an important incentive for overspending on health care.

But the shorter answer is that 2009's health-care bill will not solve our cost problem. it will put us in a better place to do so later on. But it will not, on its own, be sufficient. in a way, health-care reform begins, rather than ends, here.


Newton, Mass.: Do you expect a "public option" that under current House and Senate proposals, the CBO expects to see enrollment of 0-10 million to be robust enough to create downward pressure on insurance premiums?

If the "public option" as envisioned by Hacker was supposed to start out with enrollments of 123 million, does a public option with CBO expected enrollments of 0-10 million create the same market forces of the original public option concept?

Ezra Klein: Not really. I don't think the public options being considered will have a huge impact one way or the other, and certainly not in the short-term. For one thing, they can't use Medicare rates over the long-term. For another, a very small number of Americans can buy in, because the public option is only on the Exchange, and the Exchange has limited enrollment.

That's not to say they're not a good policy, and couldn't prove important in the long-term. But at the outset, I'm not expecting much from them.


Washington, D.C.: One of the many miscalculations of the Clintoncare process was letting committees go hog-wild in coming up with whatever they wanted; single-payer in one, hybrids in another and so on.

1. Do you think that the White House is playing a more active role in getting basic elements -- like the public option, employer/individual mandate, etc. -- to be standard across all committees in the House and Senate?

2. Are committees the biggest obstacle at this point? In other words, if bills can reach the floor, are we likely to see passage?

Ezra Klein: It's hard to say. Clinton didn't "let" the committees do anything. They just...did stuff. The White House, as we're seeing right now, how limited power over the legislative branch. Anyway:

1) I think there's consensus in Congress and the White House that uniformity, or something near to it, is important. No one wants 1994 again.

2) Nope. The Senate, and in particular the filibuster, is the biggest obstacle at this point.


Santa Barbara, Calif.:

I agree taxing gold-plated benefits is a good source of revenue (and a good way to win support of Grassley, etc.)

But how much would it really bend the cost curve? Health care isn't like buying a car. When we're sick we go to the doctor and do whatever they tell us to do.

Ezra Klein: That's sort of true. There are a couple different points of decision-making in health care. One is when we have a heart attack. As you say, not a lot of comparison shopping then. But another is when we choose a health-care plan. An HMO really is cheaper than a PPO, and there's no difference in outcomes. But the way the tax code is set up now encourages people to choose the pricier option. So you could save real money there.

Moreover, if health care is eventually taken away from employers and workers understand the full cost of it, there will be a lot more pressure to hold down costs and change the system. One of the reasons the market in this stuff is so screwed up is that workers are so insulated from the cost of it.


London, U.K.: Why does a simple comparison with health care in other countries not cut it with the U.S.? The U.S. does not have the highest age expectation in the world despite spending the most by far from GDP on health. Why? How come the fact that e.g.. U.S. citizens have to pay up to 4 times as much for the same drugs as the British NHS, doesn't even seem to register in the debate? When will the American people understand the negative nature of the stranglehold that Healthcare and Drugs companies have on them?

Ezra Klein: I think there's a sort of cognitive bias here that makes it hard to face up to these facts. People begin from the belief that America is the best in the world. And there's some reason to begin there: We are the richest country, with the most Nobel prizes, and the most highly-paid doctors, and so forth. And then they try to figure out how to match our health-care system to that belief.

That gets you weird rationalizations. Some people think we have way better technology than everyone else. Others believe we drive innovation for the whole world. Others believe every other country is best by hellish waiting lines. None of these things are measurably true. But they fit our initial bias, and so we cling to them.


San Jose, Calif.: Ooh, I really liked your Safeway/bodega analogy. How about eliminating the middleman altogether, or at least having them coordinate more closely? Medical co-ops seem to be successful in improving care and reducing costs by consolidating the health care and insurance process under one roof. Why not encourage more of that?

Ezra Klein: I'd love to do so. I've not seen any good proposal for eliminating insurance altogether and creating a system that's more like the Mayo Clinic or the VA health system (where the people who provide you coverage also employ your doctors, and so everyone's interests are aligned to keep you healthy). That would be really hard to do given that the system has evolved in a totally opposite fashion. But it would be great if we could...


Chicago: Which Democrats are threatening to filibuster? They should have their bluff called.

Ezra Klein: None are. But nor have folks like Nelson and Landrieu ruled it out.


Lexington, Va.: Hey Ezra - I really enjoyed your article, but I'm wondering, with all the references to European-style health care, what role homogeneity plays in the success of these systems? Many European countries are far less diverse (economically, ethnically, etc.) than the US, and going beyond Europe, Japan's population is almost entirely homogeneous. Don't these systems that you have mentioned depend largely on the ease of applying universal care to a population that doesn't vary from person to person like the US does?

Ezra Klein: Not really. Some of those countries are more and less diverse than others, for one thing. And it's not as if Montana, which isn't very diverse, has an awesome health-care system. It's arguably the case that there are fewer political obstacles in a more homogenous system because it's easier for voters to feel connected to one another. But there's no real reason national health insurance should work with 20 percent diversity but not 35 percent diversity.


Evanston, Ill.: Will Ron Paul's bill to audit the Fed gain any traction in the Senate?

Ezra Klein: Nope.


Arlington, Va.: Ezra: If the Administration somehow manages to get reform passed, what would happen to individual state plans, like Massachusetts's (or even Utah's, described in yesterday's op-ed section)?

Ezra Klein: They'd be largely preempted. Massachusetts would hardly notice, as the federal plan looks a lot like their plan. Utah probably wouldn't see much difference either. The thing about state reforms is that, aside from Mass, they're extremely modest.


Wokingham, UK: Is it possible, in the end, to cut the costs of health care without cutting the remuneration of doctors?

Ezra Klein: You can cut them somewhat. But in the end, no. If you cut costs, someone is going to make less money. Every dollar that flows through the system is a dollar of profit for somebody. And right now, we're trying to do health-care reform such that nobody loses much profit.


D.C.: Out of curiosity what measures do you use to measure the effectiveness of U.S. health care? Thanks. Really enjoying the blog.

Ezra Klein: It's a hard question. Very crude measures like life expectancy and infant mortality have a lot of non-health care components. Cost in one measure. But the best is probably what's called "amenable mortality," which measures deaths from things that health care could have treated. And we trail terribly on that. The Commonwealth Fund did a good analysis here.


Jacksonville, Fla.: I haven't heard much about getting rid of Medicare and Medicaid HMOs. These middlemen add a large amount of administrative costs to government subsidized health care. Wouldn't eliminating subsidies to these entities save taxpayers millions, if not billions of dollars, just as eliminating private loan company subsidies has saved taxpayer money in the distribution of federally administered student loans;

Ezra Klein: Eliminating subsidies to the Medicare Advantage plans -- which charge about 120 percent what Medicare does per patient -- is almost sure to happen. It's one of the main ways in which we'll fund health-care reform.


Newton, Mass.: A lot of free market types don't like the idea of customers knowing the calorie content of their restaurant meals. Why is there such an objection to this? Have you seen any estimates on the cost of calculating the calorie impact on restaurants?

Ezra Klein: I have no idea. Henry Waxman once mentioned to me that most consumers take for granted the nutritional information on packaged foods in the supermarket, forgetting that it was a huge fight to get that passed. One day, I think calories on chain menus will be much the same way. It'll be a fight to pass the bill, but once it's in place, no one will understand why it wasn't done sooner,

Oh, and the cost is trivial.


Ezra Klein: Thanks, folks!


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