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Update: 2017-06-08
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Sarah, Ezra, and Matt talk about competing single-payer bills in Nevada and California, plus research on the value of access to the Obama White House.

Following script is auto-generated by Speech to Text Technology:

we've sponsored by The Great courses plus Senate today at The Great courses plus dot com slash weeds and I make about six huge boxes offering our fans fifty percent off your first order of nature backstab com slash weeds hello love no I do this right Hello welcome to another episode of the weeds in the Vox Media podcast Network I met Yglesias at joined by Ezra Klein and stare we've got a busy busy shows worth of stuff to do and that Sarah has his place to go but our already busy busy busy person I was a time for the IT stuff if you are not that busy and when I was in some other podcasts YouTube and check out our guests in is the guest this week on the Ezra Klein show as a kind is also here to my left she's an expert on Russia authoritarianism I really think of myself this year left me food and only later to um I guess it's been a great part time or putting she's been reading a bunch of great pieces in the New York Review of Books looking at Donald Trump to the Russian lands his Russian American journalist who has a real sort of fascinating perspective Some has covered politics in our talk with C and applies to Trump but she's also become a little bit disillusioned with which he sees the rise of conspiratorial thinking on the left or on Trump and Rush and the sort of hope that this would be a day sex Micah now that the store is a Trump administration so we sort of talk about all things Russian shop it's a fun competition I think it isn't like it meanwhile they have to show the Americans the kind of fictional story in which Russian intelligence has only very low level access to the American government I gave it to show others our job iceberg and jewel fields are Todd van to wear this cast sat on his podcast I think are interesting it's really one of that one of the best shows of recent time and has become oddly politically relevant should be as fascinating conversation also because all things afresh are conspiracy mushy guests and turns out to be the translator for auction on the Americans wow I know it's great to know it all ties together this week on the weeds however we're going to be ignoring Russia in all of its aspects and talking about the subject of healthcare it's never really come up in the corruption in the Obama Yes we can talk about health care talk about some interesting research done on the Obama administration exciting things are happening in the state so we're not going to talk about congressional Republicans behind his ear to talk about people who are actually pass a policy isn't those are people's lot of shade to work in state legislatures right now search remember we did our very first episode of the weeds ever was about single parent is more like a theoretical discussion looking at like the benefits in the trade offs like in theory how could this work you about because of the year and half later we actually have two really interesting state level examples of what single pair could look like in the United States of the two are going to focus on the two I found really interesting the first is California which has gotten a lot of attention for the single payer bill that moved through it sound state Senate does not move through the assembly at the governor there has been a little better as concerns about the bill that this is kind of the tradition all when we listeners think of single payer is probably something like the California plan where everyone moves on to the same healthcare plan it looks alot like Canada you know you've everyone getting coverage through one plan offered by the government and its discovery lies on a lot of attention because it made it through the state Senate they're going to analyses that show how much it cost it would lead to very large tax increase in order to finance a bill like this and I think there is some unwarranted skepticism of the those reports that they might actually be underestimating the costs both of those reports were sponsored by people who support this bill so there's no reason to believe that they're relatively optimistic costs estimates that California is really kind of turn the state into a Canadian style single payer system and more generous even more dreamers as this is a zone will get into Hellfire love it but a few months ago I came across what I actually think is a wave more realistic an interesting approach to expanding government health care and it's happening in Nevada which is like not this state you think of is like the hotbed of like progressive activism I was a little surprised to see this bill do about it so much shit from progressive activists know what I'm working on a three years of activism in Nevada's of your progressive activist tell me what your state is such a hotbed of activity please email me at Sarah Fox this is sprinkle care were talking so yes in Nevada that I may to Nevada was his bill that has passed through the state legislature is going to the governor's desk that would essentially create a Medicaid by it would let anyone who wants to sign up for the Medicaid programs a lot of times we've talked about Medicare for all of the national level this would essentially be Medicaid for all it is sponsored by a state representative their name Mike sprinkle of you told me Sometimes people now call it Spiegel hair was all identical this makes me think the cupcake when you enroll just a really delightful but it's a really interesting and surprising approach that we haven't seen any state experiment with which really surprises me that I Connecticut or or summary states that end of reliably liberal governments you didn't get to this first day and basically let anyone wants to enroll in the state Medicaid program their first order question on this yet you can see do that on its own no so that the great questions of this is something that even if the governor signed that I'd say there's still the questions of whether to be an apt add some of the big questions are How much do you charge for premium to buy Medicaid how to use at that price do people in the Medicaid by and get access to federally mandated drug discounts that Medicaid gets will be trucked administration let Nevada expand a program that is trying to slash and half so there is a lot of uncertainties a rate of the biggest kind of first order uncertainty is will the governor sign at us his office didn't respond he hasn't said anything that I've seen in the press he is kind of a moderate Republican and so we don't fully know where he is out of this issue even if he does sign that there's lot of questions Will the federal government give them the waivers how you actually structure something like this and you know since I wrote my story I choose and that some people saying well here's this hurdle here that hurdle how they solve that and it's completely true there's a lot of things that have been solved but I think the way they actually thought through and see if there's all the problems are actually passing a bill like this and then working towards and I think to understand the distinction between what they're trying to do in California and what they're trying to know that I think it's helpful to think along like two different dimensions of difference white one is the buy and model versus the government funded model right where so California is basically saying they have to work out exactly the details of it but everyone is going to pay a lot more taxes but in exchange everyone is going to get free health insurance from the government so you know already you are sort of implicitly paying alot for health insurance of your insurer and that's going to become an explicit acts you know so it's it is a very large fiscal and economic changes and big whereas Nevada is proposing to say you could take the money that you are already spending on health insurance and instead take that to get yourself into a government program right so in principle you could do Medicare through the Bayan structure or you can do Medicaid pays its structure but that is one difference is that Nevada is a buy and less explicit taxes than the other is Medicare versus Medicaid which does a lot of relevant differences but the main one is reimbursement rates wide so that like when people will tell you how a single payer system could actually save money with them means is that most countries that use single payer systems that use that sort of government monopoly to say we're going to pay pharmaceutical makers hospitals doctors less than they get paid in America may care already has that structure it pays less than private health insurance as Medicaid pays even less than Medicare does so it's it's sorta cheap but at the same time you know the less you willing to pay doctors the more health care providers willing to turn patients away so you can think about the cost estimates for California in part have to do with how much is the state really going to squeeze health care providers right where is Nevada's approach is like saying right from the go like this going to be a lot of squeezing of health care provider site just the Rings unlike number says the California approach they are right now they're proposing they would just use Medicare rates that they would say we're going to pay doctors what Medicare pays it's kind of in the middle of Medicaid private insurance we think it's a fine deal I don't fully know how California doctors would react to that but not positive I assure that in Nevada when things you see is that Medicaid in Nevada pay is eighty one percent of what Medicare pays using like cut on top of that so that's one of the ways you get to so dearly out in just some other big differences here that want to make sure you just put it as a frame in this conversation one is that we're looking at a different spin like a big bang single payer transformation in California and in Nevada a slow transition in which maybe it never gets to single payer right it's just there's a Medicaid buy in option so in California the way that Bill a structure I believe reading it correctly an insurer could not offer insurance duplicating the coverage of the California plan I mean this isn't really much more like a Canadian plant you don't have private insurance anymore if you work for Facebook in California and you enjoy whatever gold plated coverage Facebook that's you know it's possible there's going to be secondary insurance a supplementary insurance against you even better better deal but you are it's done um like the private insurance like you make it smaller fish on it and about one key difference is like your network becomes the same as anyone else like you end up getting access to credit for that reason I think they've structured the He proposal as being like incredibly generous much more generous than any single payer system I know is right there to cover anything up medical provider deems necessary there are no co pays are no deductibles the Senate Appropriations Committee has not really an analysis of the description of the plan with or dislike we have no way to control costs and the structure but that's a big bang single pair and bought it isn't and then this also does I think is pretty interesting issue of Just transition The Californian doesn't really have a transition that something that is left completely open on the Nevada Plan is all transition ever as an end state and so those are really different ways of imagining what you're doing here one is sort of allowing people to choose to opt into a single payer plan if you think of how the Nevada thing would get her something like single parents that Medicaid is cheaper people like it and people would over time choose it more often tell it becomes less less profitable for interest remain in the system because they're competing at such a price disadvantage that they begin to collapse on the single payer plan conferences like this just done there's no there's no private insurance is to speak of anymore so that seems just a big deal right I met in California is one thing a very different states for a different kind of state economy is and if you did something like universal Medicaid buy in California I think lots and lots and lots of Californians wouldn't take it California is a relatively affluent state with a number of really big cities are like huge globally competitive companies like Google Facebook Apple and the like Wharf programmer talent are not going to try to like save some money by enrolling their staff and many Katie even have that option became available I was not that is as below average incomes stayed very heavily service economy has a lot of people and employers who I think would genuinely benefit from like cheap sort of workable basic health insurance even in affluent people might still serve up couches for saying that with that would give them broader options but there's a sort of like logic to it although the legend that goes in the other direction is that you know one issue that I think Vermont had to think about when they were considering single payer most states and think about is is this unit of government really like big enough to do those low reimbursements without sending providers like fleeing across the border of California I mean the reason why I think there's a lot of detail kind issues with this bill but broadly speaking like I think California should go for something big on this because California is so big you know I mean I sometimes hear single payer proponents say like you can't do this at the state level California for example is much much larger than like sweet and you know and frankly Finland the other Nordic countries are generally smaller than California but they participate in a currency union with the EU to constraints of deficit spending and stuff like that elephant is a bigger economy than the bigger cunt in Canada it's close it's more people um so you know E is thus economically bigger by the European countries are able to pull this off under the same kinds of constraints that California would be facing and it seems to me that would be worth their while since California is such a progressive state to be the candidate to try to work this at right if Canadian doctors aren't all the camping for Chicago and Seattle that California should be able to come up with something workable here I think this program that they've written down maybe a little too sudden and its approach probably a little more generous in its coverage than you really don't want to do is the legislative process for that but it seems like really actually appropriate for me for California legislators to be thinking about like Big Sky had we really wanna do this quiz Nevada is honestly a state that has a little bit less like going for in terms of its intrinsic strengths and maybe appropriately wants to be a little bit more cautious with its changes and take advantage of urgent need to like make sure that low income people have accessed yeah and this kind of shapes how I think about that if either of these pass how they might ripple through the countries I think you're totally right it's really a different ballgame doing single parent California than it was in Vermont and Vermont like your doctor in Burlington at him like you don't like you know I think is called the Green Mountain Care uses like drive two hours moved to New Hampshire like Hii there are so many places you could go without really uprooting yourself like it would be given to pharmaceutical companies which is suppose we won and yelling like you could walk away from Vermont farms in California your doctor in sentences go your doctor in Los Angeles lake you really going to go far to like get out and you go to Nevada with Medicaid plan or something that you really there just isn't as easy and I think the scale of it suggests like I think that's right that like tough when you could do it there's also a bill moving through the New York legislature right now that's also been getting a little bit of attention and those who make the places that I think could really pull this off because they're so large because it is very hard for doctors to get out get out of those places and kind of like maintain whatever life they set up there but for that reason it seems really hard to see how a California system like my scale one thing you could think of is like other states tapping on one thing I thought about is if you have like a left coast single there's a summer like Oregon and Washington kind of like layer on top of California in all this and you have like this trio of liberal states that are part of this continue and they can kind of leverage what California's done but it's really hard to see you for me like how it would move eastward from there like whether smaller states in the Midwest of the political interest or the ability to kind of hang on to their medical community the other half you could see a taking is like the Massachusetts The author once it does it really well actually that's the Canada path to where you like one state one province doing really well and in the national government gets interest ed Nevada I think it's more and fragile is really the opposite where you could see unlike spreading like a really random array of states or dislike interest in this idea I think particularly state's rate now that her saying to see holes in their Obamacare marketplaces the Great now we have Missouri has a number of counties with no Obamacare insurers on Ohio to send out as twenty counties that were known wants to sell coverage next year and met if you buy and that doesn't really require as much scale I think because it's so gradual and so that's when I could see really moving like cropping up in like a weird random way in a number of states did like the actual characteristics the state seems more applicable in other place as the Ana California approach my pace a few thoughts on this one thing that I think is interesting about the difference between Big Bang single parents and the Medicaid buy in is it that the Medicaid Buy In model creates a mechanism by which the provider networks can tell which is to say that imagine you do the Medicaid Buy In model in Nevada and provider networks look at that and this is this is an existential threat right we do not want to move to a cost structure we are assisting on Medicaid payment rates were willing to do that for the pour is a bit of a stretch when Obamacare expand it but Obamacare also came with increases in Medicaid payment rates so that you know and more people so there was some kind of tradeoff here but were afraid of this in that world what you do and we have you seen this in other countries I mean there are examples of this on small scales they could stop accepting Medicaid rate they would just move their provider Max to private insurance Amen and you know people talk about that happening right now on Medicaid it has not happened in very large numbers but it does happen on the margin there are providers out there who will not accept Medicaid or will not accept new Medicaid patients particularly to see that quite a bit and so one thing that in California under the spell if you want to be in California going to live in hell for help which a lot of people do mice live in California it's quite nice you have to have to be part of the plan right there's nothing else you can do really I think some of the concerns about people accepting Medicaid a little overblown when you look at the data like just today I was looking at when I was reading the Nevada story is a thick it's like eighty five percent of providers say they're accepting new private insurance seventy percent say there's a difference but I do is not desires the tuition industry began to think Medicaid was a threat to them right it was like a step towards full single pair you could imagine going up and Chris were teachers I don't think it's a reason not to do it I just want to know that's one of the things that is an attraction of bigger single payer proposals they don't allow this kind of mom ensure shopping they could be a danger than the other thing that I was struck by studying these proposals in my sort of I knew but I didn't know was actually how much and the state based transition to single payer or something like single pair relies on the federal government allowing it so in California more than half of the health care spending has come to the federal government so they need the federal government to give them a waiver allowing them to take all that money is routed through Medicare that is right to Medicaid I don't remember these VA in here potential Obamacare subsidy Obamacare subsidies are higher the subsidies to leave if I read the thing right it also wants to cash out the employer provided health care tax break the ice something something I read in the analysis by four professors alike am who I think it is a UMass Amherst yes I think if I was interpreting that right they I think we're talking about I don't know for sure so another one a state that is all to say that one the federal government have to create all that right agree to let him use Medicare East also be letting them use all the money and second there lay the federal government has regulation over bunch of these aspects of the system reset which I'm not going to try to remember what the acronym stands for future employee retirement insurance something the rest of my purest it is a bill that gives the federal government among other things regulatory control over self insured employers and millions of employers in California self insure so that we need in a recent waiver in order to cash it in turns out in or have regulatory authority over over that piece of the Marquette just a lot this year that the federal government would have to say yes to me you can imagine you know an Obama administration are Heller Clinton administration possibly saying yes to these things right they are maybe they would prove not to be right but conceptually they're in favor of experiment with things like single payer but even they might be pushed back by pharmaceutical lobbies and other things Trump administration or some other public and this ration the Mike Pence administration would not allow this at all and so one of the sea interesting things in all this is it to make any of the numbers work here you really do need the federal money to be routed to your control and for all the Republicans are like for federalism I don't think fit virtually any of them would allow the lead Nevada as in a similar situation where they also need a waiver to let people buy into Medicaid only the monies it's a smaller ass you're basically saying like these people finance that but again it's hard for me and they are representatives for God has told me that his conversations with a justice of our positive but obviously like to say like actually think this is doomed go nowhere the federal government to the third dependency on that that is when a node is that you also because you or because you're relying on the federal government funding streams your actual island is funny to me relatively stable yes so right now Republicans are trying to pass what is at eight hundred in its more as a massive the half with four children in Medicaid cuts that would really fuck up one of these plans because they're expecting that they have that money to work with and they have that level of reimbursement and match and such or if they don't have that that means have to raise taxes by even more and these tax increases are high even these relatively rosy estimates you're looking out the single payer plan in California costing more than the California budget costs city or state's projected spending is one hundred eighty billion next year the purplish Committee has a four hundred billion dollar estimate on this plan that's a very big Tex else wacko points that that they think are important there what does that mean a political level that's all sort of like a reason for California Democrats to plow ahead with this because it means that in the sense you don't need to actually worry about the full book ability of some of these details you're going to pass said You're going to come up with some waivers that companies face is going to block you then you can get to have a I think would be used politically useful for Democrats to be able to settle on we need the next president to allow states to experiment with single payer can finally win California The California to resolve intra party tensions over like do Democrats need to embrace Bernie care or can you be for single payer without being like for single payer by saying we're going to facilitate California Nevada anybody else can experiment and I think I think is really important it to keep in mind here's the difference between the economic cost of a program and the budgetary cost of a program of rights or that something like a universal paid family leave program for the United States would have a large budgetary cost and would also have a large economic cost you would be talking about taking lots and lots of people who are currently working and having them not work because they would instead be at home taking care of children or sick relatives would something like the California plan you're talking about a gigantic budgetary costs right this painting is just huge relative to the current spending of the California state government but in principle at least the economic cost is not that high and I see people sort of confusing these things in both directions one is when the appropriation Committee analysis came out there lot alike scare stories oh my god this program would cost three times as much as California spending or something but a lot of that is just like taking a federal spending and like making it state spending a lot of it is his new taxes but the resume having the state government of California foot the bill overrides medical care would expand the budget a lot of Californians are already spending an enormous amount of money on medical care you're not talking about a huge increase in the actual utilization of resources to get some people like these at UMass Amherst economists who I think it like to keep with that and they start saying things like Well if you look at all the money that is being a pseudo spent through the employer tax exclusion you know we're not really talking about any awe I mean they go further right there saying that the net the plan will save percentage so actually it's like and what net budgetary cost is relevant even if it's not the seams economic costs like the Appropriations Committee throughout as a like for instance you could pay for this with a fifteen percent payroll tax increase I know it's true that if you look at a sort of typical middle class full time employed person and you look at what how much of your money is implicitly or explicitly going to insurance versus the fifty percent payroll tax you coming out similarly but their people and different margins who would come out very very very differently right so like if you're talking about a sixty two year old who is eligible for Social Security benefits but not yet eligible for Medicare the difference between working and getting health insurance exchange for working and getting health insurance whether you work or not paying a fifty percent payroll tax if you work but not if you don't work that's like a huge difference right in there would be a big economic cost in something like that so you don't need to pay for it with that with a payroll tax you could pay for it with a value added tax that kind of sales tax that would be the more European style way of doing it in that case I think you'd have much less of an economic impact is people still have the same kind of reasons to work you would be saying who are already getting Medicare are going to keep getting Medicare but they're gonna start paying higher taxes for everything that they buy in order to finance the summer jobs program for everyone to me that seems like it like a fine idea I would be all for it but the politics there are tricky but just to say that even if you believe that this can be no net economic cost of the transition or that this can be economic efficiency is you still have to think about how you handle the budgetary issue because the way that you handle it makes a big difference in that in the Amherst paper they suggest a I believe it's a two point three percent of gross revenue tax receipts less gross receipt tax which is like I think the financing mechanism you pick because you want the number to sound a small was there was a grocer so the tax is it's like it's like a barbaric if you ask a buisness ok how much stuff you sow and likely solve whatever million dollars he paid tax on those gross sales right so if you bought like nine hundred ninety nine dollars worth of stuff and you sold a million dollars worth of stuff and had almost no profit now paying two point three percent of gross revenue and like you're at a business write anything could happen revenue not just on prop eight s revenue and to encourage is increasing huge distortions because it means that if you can vertically integrate your revenue is only taxed once you're paying a much much lower rate than if you have like a huge chain of suppliers and that's why I like real countries use a value added tax which backs out the expenses and means that how much tax you're paying is indifferent and the only good reason I can think of to favor the gross receipts approach over the value added approach
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