Diane speaks with Dr. Roger Kligler who is living with advanced stage cancer on why he's suing the state of Massachusetts for the 'Right to Die' and with Dr. Jessica Zitter, and intensive care and palliative care specialist on why better communication is so needed between doctors and patients facing end-of-life issues.
Health insurance coverage under the Affordable Care Act begins. The new mayor of New York City promises to tackle income inequality. And state regulated marijuana sales begins in Colorado. Diane and her guests discuss the week in news.
- Annie Lowrey economic policy reporter, The New York Times.
- Manu Raju senior congressional reporter at Politico.
- Naftali Bendavid correspondent for The Wall Street Journal, currently based in Brussels.
Bendavid, Lowrey and Raju talk about why the Republicans must win their congressional races in 2014.
MS. DIANE REHMThanks for joining us. I'm Diane Rehm. Health insurance coverage under the Affordable Care Act begins. Bill de Blasio is inaugurated mayor of New York City and promises to tackle income inequality. And state-regulated marijuana sales begin in Colorado. Here for the domestic hour of the Friday News Roundup, we welcome back Naftali Bendavid of the Wall Street Journal, Annie Lowrey of The New York Times, and Manu Raju of Politico.
MS. DIANE REHMAnd throughout the hour, we will, of course, welcome your calls, your comments, your email. Our number is 800-433-8850, our email, firstname.lastname@example.org. Follow us on Facebook or send us a tweet. Happy New Year to all of you.
MR. MANU RAJUHappy New Year.
MR. NAFTALI BENDAVIDHappy New Year, Diane.
MS. ANNIE LOWREYHappy New Year.
REHMGood to see you. Annie Lowrey, what is the impact of the Supreme Court likely to be on the healthcare act?
LOWREYSo I think that what we're seeing now is -- you know, since the major ruling about the Medicaid expansion, there's going to be a number of rulings about some of these smaller issues about who has to provide what and how. Right now, Sonia Sotomayor has issued an injunction that is going to -- deals with this issue of contraception and religious institutions.
LOWREYBut it's not a ruling, so we don't know how this is going to play out yet. And it's just one of these things that we're going to have to watch. There's going to be a lot of these issues as the law gets implemented 'cause it's so complicated. It affects so many insurers and institutions and people.
RAJUYeah. You know, the Supreme Court's going to have to hear two cases involving the so-called contraceptive mandate. I mean, with the -- the administration's sort of been in a bind on this issue because the president says that all women should have access to contraceptive coverage. But what they're trying to do is sort of split the difference with these churches who say that they should not be able to expand -- they should not be required to pay for contraceptive coverage for their employees.
RAJUSo what they did is they provided this exemption for these churches and religious-based organizations and allowed those employees to get the coverage on their own, so long as the employers were not paying for that. But that did not deal with private institutions, private companies whose employers' religious beliefs actually run counter to providing contraceptive coverage. And that issue, involving whether or not private sectors -- private employers can deny this kind of coverage to their employees based on their religious beliefs, that's going to be the center of the Supreme Court cases this March.
REHMBased on the religious beliefs of the employer.
RAJUThat's right. That's right.
REHMWhoever that may be.
RAJUThat's right. And that could have a really profound impact if the justices side with the -- against the Obama Administration.
REHMAnd, Naftali, you've been in Belgium for these last few months. How are politicians there watching what's going on here?
BENDAVIDWell, I think to some degree in Europe, they don't really understand why we wouldn't have universal healthcare coverage. It's just a different approach to these things. And every country in Europe has a sort of what we would call a single-payer system essentially where healthcare is provided through the government to everyone. It's the kind of thing that's politically not possible here at this point. But it just goes to show, you know, these are some of our closest allies in the world.
BENDAVIDWe're culturally and politically very similar, but in some of these basic political and social questions, we're still pretty different. For that, they don't understand how we can do it the way we do. And a lot of people here, I suppose, can't understand the way they take the approach that they do.
REHMHow well does it work in Belgium, for example?
BENDAVIDWell, I mean, I can speak a little bit from personal experience. And it seems to work -- it's worked very well for me and my family and for the people that I know. There's a whole sort of different approach to medicine there. It's a lot more casual. You know, if you call the doctor's office, the doctor will often answer the phone. You'll go into his office. He might be wearing jeans. He -- when I paid my doctor, he pulled out his wallet and gave me change. I mean, it's sort of -- there isn't the sort of removed almost imperial or imperialist approach to medicine that we tend to have here.
REHMThat's very interesting. But the question has always been how much it's costing these European countries, like Belgium, to carry on that single-payer system.
BENDAVIDI mean, I think -- you know, I mean, I haven't looked at the studies in detail. But I think it's a general sense that at a relatively low price, their outcomes are as good or better than ours. I mean, I think the evidence has shown that. I think people here, though, are very caught up in the idea of choice, the idea that they won't be able to get whatever treatment they want and have it paid for whenever they want it is something that's very important to Americans.
BENDAVIDI think Europeans, to some degree, are willing to make more choices about treatments that may be too expensive, for example, and perhaps not as proven to provide to everyone under any circumstances. So I think that's kind of where the big culture and political differences come into play. They're willing to give up a little bit of choice and a little bit of guaranteed access to everything in a way that a lot of Americans are not.
REHMYou're a young, healthy man. Presumably, so is your wife, your children. Did you experience any frustration in having to make those compromises?
BENDAVIDI mean, we have not. But as you say, we haven't engaged the healthcare system in any sort of in-depth or extensive way. We just haven't had that experience, so it's hard for me to, you know, comment on that. We haven't had a lot of problems. But you're absolutely right. We're not in a situation where we've had to really deal with a healthcare system in a long-term or in-depth way.
REHMManu, the administration is assuming that 7 million people will enroll in the ACA by the end of March. How realistic is that?
RAJUWell, they're off their projections right now. I mean, earlier this week, Kathleen Sebelius announced that 2.1 million people signed up through the state and federal exchanges. That's off their target of about 3.3 million. That was what the CBO, Congressional Budget Office, projected that they would need to be at this point in order to get to that 7 million mark.
RAJUIn total, it's about 6 million when you add folks who have joined through the Medicaid expansion, as well as through the children health insurance program. It's certainly better than where they were in October, but there is quite a way to go. And they're going to have to deal with a number of snags in the process along the way that will undoubtedly be highlighted by Republicans.
LOWREYYeah. And I think that the question is not so much, you know, are they going to get this many people by March? But is the process going to be easy enough that it's pretty frictionless for people to sign in -- sign up, especially when the individual mandate starts to kick in. What we saw in Massachusetts, which implemented a not dissimilar but state bill back in the 2000s, was that people really delayed signing up until the last minute, until those penalties started kicking in.
LOWREYAnd it looked like the penalties were actually very effective at getting people to buy health insurance, even if the penalty was smaller than paying for the plan itself. And so that's the hope for the Obama Administration too, is that, you know, in 2015, 2016, the coverage has really expanded in the private side.
BENDAVIDBut I also think there's this broader political question of when we sort of reached a political tipping point where so many people are now engaged with the program either through the Medicaid expansion or through the exchanges. It becomes very difficult to repeal it or to change it in any meaningful way.
BENDAVIDAnd every 100,000 additional people that is getting healthcare coverage through the ACA, I think, brings us closer to that point and makes it difficult to either repeal it or to make fundamental change. So I think these numbers, whatever the projections initially were, they have a certain political ramification that shouldn't get lost.
REHMDo you agree, Annie?
LOWREYYeah, absolutely. The history of these programs is that once you give people something, it is very, very, very hard to take it away. Maybe you can substitute something, right? There's this idea that you could block grant Medicaid or change these programs pretty profoundly. But you can't take the entitlement away once it's given. And, again, millions of people have signed -- it's something like 2 percent of all Americans have signed up at this point through the ACA expansion, so a lot of people.
RAJUYeah. And, you know, the challenge will be selling this in the short term. I mean, 'cause right now the views are very negative overall over the law. You know, all along, Democrats have been saying, you know, once the people experience the benefits, once they get the coverage, then the public opinion will shift in their favor.
REHMAnd now we're hearing more about the benefits and the people who have experience.
RAJUThat's right. And the question will be, to what extent that encompasses, you know, the majority or vast majority of people who are now involved with this program. But a lot of people may not experience really any change at all in their personal lives and their habits, and they may not understand what all of this fuss is about. So that may impact the overall perception of the law as well.
BENDAVIDWe're also entering an interesting period because people now have the coverage. You know, it was until now, the talk has been about how hard does the website make it to sign up? But now people have insurance, and they will go to their doctors, go to their hospitals, and say, here's my insurance that I got through the ACA.
BENDAVIDAnd will it work? Won't it work? What kind of records will be kept? So I think we're entering this really crucial three-month period, at the end of which the individual mandate kicks in. And so how that is sort of reported and felt by people in the next few months could be really important.
REHMHave there been any surprises, Annie, that you have encountered as you've reported on this?
LOWREYWell, I think that one thing -- I think that people have probably focused a lot on the exchanges and not so much on the Medicaid expansion. The Medicaid expansion has been going really well in a lot of the states where they've expanded the program. And I think that the issue in a kind of crass political sense is that these people tend to be poor.
LOWREYThey're disenfranchised. They tend to be childless adults with very low incomes. So, you know, I did a story about signing the homeless up for Medicaid in a lot of states. And I think you'll start to hear a lot of -- more good news stories coming out of that expansion. But it's not as politically potent a topic, except in the states where they didn't expand.
REHMWhat about this question of more people going to emergency rooms under Medicaid?
LOWREYRight. So this comes from a kind of an amazing social science experiment called the Oregon Health Study. And it found basically that Oregon lotteried Medicaid to childless adults that created this great natural experiment for them to study its effects in isolation. And people used the emergency room more.
LOWREYAnd to a certain extent, economists weren't surprised by this because it makes it easier to use the emergency room if you have health coverage. But it really undercuts one of the central arguments for the law that the Obama Administration made which is that you can cut cost if you can cover people because you can rationalize care. And it doesn't seem like that's true for preventative services and for emergency room use.
REHMAnnie Lowrey, she's economic policy reporter for The New York Times. Short break here. We'll be right back.
REHMAnd welcome back to the National Hour of our Friday News Roundup this week with: Manu Raju of Politico, Annie Lowrey of the New York Times, Naftali Bendavid of the Wall Street Journal, currently based in Brussels. We have three emails all asking about the same issue. Let's see. This one is from Deb in Ohio.
REHM"If an institution like a Catholic university accepts federal monies, shouldn't they then accept various federal mandates like contraceptive coverage or forego any and all federal dollars to their institutions, for example, for research or student loans? I realize it's a philosophical question but one worth discussing." Manu.
RAJUYeah, and I think that's one of the things that the proponents of this law will be eager to point out is that, look, a lot of these institutions that do receive federal dollars should be required to do what the federal government wants.
RAJUThat is not an issue that -- and the White House says that, you know, if -- they've tried to accommodate some of these institutions that are concerned that are religious-based institutions, allowing them to have their employees get coverage on their own and not on their own expense, not being paid for by those federal -- by those institutions even if they do receive some federal dollars, to try to split the difference there. Clearly, that has not gone far enough to accommodate concerns though.
BENDAVIDYeah, I mean, this range of groups that is religiously affiliated but aren't churches, they reached a very interesting accommodation where the employees can get contraceptive insurance but through a separate policy. And -- but the groups have to essentially sign a piece of paper that says, well, we're not going to provide this. And that paves the way for their employees to get contraceptive coverage through another policy.
BENDAVIDBut they say that even signing that form by paving the way for their employees to get this contraception coverage violates their religious principles. So we're getting down to very delicate specific, you know, sort of fine grain questions of religious freedom. And it's going to be pretty interesting to see which way the court goes.
REHMIndeed. All right. Let's talk about both the Congress and the president who begin 2014 with very low approval ratings. The AP and the Times reported that the New Years Eve poll showed only 34 percent of Americans think the nation is headed in the right direction, Annie.
LOWREYYeah, there's some kind of weird things going on here because I think when I've talked to folks in Congress, they feel like things are going a little bit better. They finally got this bipartisan budget agreement. It looks like they're going to get to actually appropriating money in a fashion that they're designed to. But at the same time, you know, it's been years and years of them being at each other's throats.
LOWREYI think the Obama Administration has really been hurt by the botched rollout of the healthcare law. And we're kind of in the unpopular phase of the law. I think it's something that Naftali said, which is really smart is, you know, once people have this benefit, now it's going to be, you know, more stories about how they're using it as opposed to just the fact that the government's just compelling people to get coverage.
RAJUYeah, I mean, the difficult thing when the approval rating is so low for Congress and for the White House is that neither side can really trust each other to get major things done.
REHMWell, that's the point, and what's realistic for them to get done in an election year.
RAJUNot a whole lot. I mean, there's probably a short window right now to get something through. The closer you get to an election, the harder things get. Immediately on Monday, the Senate is going to take a vote -- a procedural vote on an unemployment insurance extension that stands a chance of passing as a short-term measure, three months, that could potentially pass the Senate. Its chance in the House are anything but certain because Republicans want to pay for that extension. So we'll see what happens there.
RAJUAfter that is really unclear what they can deal with, but they have to deal with raising the debt ceiling in February and March. And there is -- the only one major policy item on the agenda that really has a major sweeping effect that can get enacted is immigration. And it's anyone's question how John Boehner will deal with that issue right now and whether or not that's enough to get something through in a very heated election season.
BENDAVIDYou know, I mean, as far as immigration itself, I mean, I guess I tend to be skeptical. It's -- you know, it does seem that John Boehner may want to get something done, but how long will it take us to learn that, just because John Boehner wants something to happen, it doesn't mean the House or his own Republicans are going to go along.
BENDAVIDI mean, he's got a -- I think, you know, John Boehner probably sees the immigration issue the way many mainstream establishment Republicans do, that the party needs to do something on it. But there doesn't seem to be the political movement to enable that to take place. So we may be looking at something where for the rest of -- you know, until 2016, very little happens in Congress. And with this group just kind of getting the budget passed in any sort of a normal way seems like a big accomplishment.
REHMWhat about the farm bill? Doesn't that have to get passed, Annie?
LOWREYYeah, that's another -- one of the few but big things that's on their docket. And that's been just enormously politically tough because there's so much stuff in it because it's this big kind of expensive thing. And, you know, I think that there's all sorts of components of the farm bill where they're going to be facing these fights about, you know, cuts to food stamps. And it's very difficult to see them coming together to get a lot of these big kind of gnarly issues solved.
REHMWhat about the appropriations bills, for example, covering commerce, justice, homeland security, all of those, Manu?
RAJUThey have to get that done by Jan. 15, otherwise the government will shut down. Right now...
REHMAnd they're not going to do that again.
RAJUIt doesn't appear that way. After the budget agreement, they reached a top line appropriations number of 1.012 trillion for discretionary spending of the defense and nondefense side. Both sides have been trying, over the break, to put together a bill to deal with the program by program funding levels. Democrats will have to agree to about $14 billion in cuts to the domestic side of the ledger nondefense. And the Republicans would have to agree to about $25 billion on the defense side.
RAJUIt appears that they are able to bridge those differences. The leadership does not want to make this a fight about Obamacare the way that led to the October shutdown, so right now things appear to be moving smoothly. But that will only take us to October, and it'll be right before the election season again where they're going to have to pass another appropriations bill or face a threat of a shutdown.
BENDAVIDBut if you listen to what we're talking about, these are things that should be Congress' basic job.
BENDAVIDI mean, we're talking about, like, if they pass a budget and if they raise the debt limit and if they pass a farm bill, oh my god, I mean, you know, it's a huge banner year. And so the idea of them actually, you know, passing something that's a little more sweeping and far-reaching and changing national policy like on immigration or gun control or whatever it might be, I mean, that seems increasingly out of reach. And it tells you something about where we are.
REHMWell, I'm interested in the new mayor of New York, Bill de Blasio, talking about setting a new tone and actually tackling income inequality. How might he begin doing that, Annie?
LOWREYSo I think that he's put forward a set of policies not so much to tackle inequality itself, but to tackle its effects. And that includes, you know, raising taxes on high-income folks and expanding the safety net, creating things like affordable housing units, obviously expanding early childhood education, those sorts of initiatives. But this stuff is really, really tough. It's hard for a single city to tackle this issue given the huge economic forces behind it.
LOWREYAnd a lot of New York's economic might comes from the sort of industries that contribute in some ways to this issue. There's a lot of corporate headquarters there. There's a huge financial center there obviously. So I think leaving aside the politics of how you actually pass such proposals is kind of the question of really how much you can do.
RAJUYou know, I think it's real interesting because Bill de Blasio, you know, sort of represents what the Democratic Party debate's going to be post Obama. You know, he is, you know, very aggressive about pushing for higher taxes and funding things like universal pre-K, dealing with social safety net issues, sort of that economic liberalism and that populism on the left that people who may not be -- don't like what the president has done in that regard, people who are upset on the left with his support for cutting Social Security, for instance, and not going aggressively enough to protect the social safety net.
RAJUThat is a debate that is really going to take -- going to be at the root of the party going forward. It'll be interesting to see how people like Hillary Clinton, if she does run, how much she embraces that or if she continues to carve out that sort of centrist path that she took in the run up to the '08 elections.
BENDAVIDYeah, and, I mean, the symbolism was interesting because the Clinton's were there and so was Andrew Cuomo. So, on the one hand, you had this guy who's being seen as a symbol of a potential liberal resurgence being inaugurated, but you had people like Bill Clinton and Andrew Cuomo who are really known to really -- to approach things differently, to be more centrist, more pragmatic in the audience. And so it was a symbol of, I think, some of the things he's going to run up against not only because some stuff would have to be done by Albany. I mean, he's the mayor of the city.
BENDAVIDHe's not the governor of a state. And the Wall Street presence and other stuff that Annie was mentioning but also, you know, this debate within the party. I kind of think it's interesting that there's another great city, Chicago, which is led by another former Clinton operative, longtime Democratic aid and then politician Rahm Emanuel.
BENDAVIDHe's kind of going in another way. So you're going to have Chicago and New York led by these longtime Democratic insiders trying to move in somewhat different directions and seeing how that plays out. Could be a little bit of an indication as to how things go in the future.
REHMSo if he were to put forward these ideas you're talking about, Annie, how much resistance is he going to get from Albany and how far will he be able to get?
LOWREYI mean, I think that the answer is considerable, right. Again, if you're trying to convince a state about policies for a city again where the issue that you're looking at is really structural and national and international in its sort of creation and scope, I think that that's going to be tough. That said, a lot of these kind of more liberal policies, so things like raising the minimum wage, expanding early childhood, tend to be very politically popular, you know, less over things like expanding affordable housing.
LOWREYBut I do think that he's come in in this kind of populist resurgence. And I do think that Manu's right, that you've seen a lot of people starting to tack further left in the Democratic Party. So how that actually plays out, I think it'll be -- it's certainly not that he's going to be able to snap his fingers and get this done.
RAJUYeah, that's right. I mean, I think Andrew Cuomo was very noncommittal when he was asked whether he would support this initiative, you know, one of which being that raising taxes on the wealthy to pay for the universal pre-K. You know, that will be an interesting fight. That though, as Annie's right, I mean, those things tend to be pretty popular particularly in a state -- a blue state like New York.
REHMWell, and considering the amount of money right there in New York City with those multimillion dollar condos and the like. Wouldn't you think that he could get through some tax increase?
BENDAVIDWell, possibly, but, you know, and maybe even more so because the fact is it looks like income inequality is going to be an issue that the Democratic Party more broadly is going to embrace, which isn't necessarily an intuitive thing, but they seem to be coming together around that. The minimum wage is perhaps the premiere part of that agenda. I think it would be tough to actually pass a national minimum wage increase, but that's something that they can point to. It's a popular initiative. So I think in way he is in tune with the way the party's going.
REHMNaftali Bendavid, he's correspondent for The Wall Street Journal currently based in Brussels. And you're listening to "The Diane Rehm Show." Well, Colorado is certainly a popular state. There were lines, just thousands of people standing in line to buy legal recreational marijuana.
RAJUThat's right. This will be a very interesting test -- first test, first state to do this. We'll see how it goes. You know, the proponents of this measure will, you know, say that this is going to be -- go a long way to cutting deficits, dealing with problems such as...
REHMBecause it's going to bring in a huge amount of taxes.
RAJUThat's right. For recreational users of marijuana under this law, that's a 25 percent tax on that product, not for the medical but for the recreational side. And that is huge for any product. It's probably one of the biggest, I think, in Colorado. So this could bring in a large amount of revenue to the state. It could reduce an amount of arrests and nonviolent drug crimes, something that has been pushed for by folks on the left and the right in Washington as well.
RAJUAnd it will be an interesting experiment to see how much this helps with the -- reducing the crime rate and increasing the deficit and the extent that which can create jobs. If this is a success maybe it will be replicated in other states as well.
REHMSo the question is, if someone needs it medically, they don't have to pay that 25 percent in taxes?
REHMCan't they simply get a doctor to say that they have a medical need, Annie?
LOWREYWell, there's pretty strict rules -- or there's supposed to be pretty strict rules about who can get it for what reasons. But I think if you look at the example of California, obviously sometimes those things can be shifted around. But I do -- I think it's interesting how fast public opinion about this has changed. And I think that if Colorado shows that this makes good fiscal sense, I think that you're going to see a lot of other states where you have a lot less societal opposition to recreational drug use kind of go down this path. Everybody's watching.
REHMBut, you know, the contradictory element of shutting down places where you can smoke cigarettes and at the same time allowing the use of recreational marijuana seems really rather odd.
BENDAVIDTrue. And it's fascinating the way things are going. And who knows what the Feds are going to do. I mean, technically this is illegal under federal law but they've chosen to take a wait-and-see attitude. But here's a subject where my European perspective can come into play because I had to do a story in Amsterdam. And Amsterdam is a place where you walk around, you can smell the marijuana...
BENDAVID...in the air. And so they -- there have been attempts to cut it back. It's not just Amsterdam. It's throughout Holland. And there have been attempts to cut it back, and they've met resistance. It's been difficult financially because those places become tourist centers. It's a big basis of their tourism, not to mention the culture and so forth. And so once it's introduced and becomes widespread, it does, at least in the experience of Holland, become difficult to undo.
REHMSo do you expect other states to follow suit, Manu?
RAJUWell, Washington State already has. They passed that ballot initiative along with Colorado in last year's elections. And we'll see what others do. This is going to be done at the state level. Washington is not going to deal with this. If anything, the only thing that Washington will deal -- Washington, D.C. that is -- will deal with would be dealing with mandatory minimum sentences for nonviolent drug crimes.
RAJUThat's something that people like Rand Paul, the Kentucky Republican has teamed up with Pat Leahy, the Vermont Democrat. As well as people like Cory Booker have expressed interest in this as well. So that is an issue that may be dealt with in Washington, but on the state level the recreational drug use and legalizing that, that sort of isn't going to happen.
REHMBut then you've got all these people already in jail for minimum sentencing on marijuana, holding, and use.
LOWREYYeah, and there's been a real title shift, I think, in the understanding of these minimum drug sentences for nonviolent offenders. You know, Barack Obama just recently pardoned people who were put away for nonviolent offenses. And I do think that it'll be interesting to watch how the legislation -- how the legislative branch responds to that.
REHMAnnie Lowrey of the New York Times. When we come back, we'll take your calls and talk about key congressional races to watch.
REHMAnd welcome back. It's time to open the phones for our three journalists today on the national hour, the Friday News Round-up. Here with me: Naftali Bendavid of The Wall Street Journal, Annie Lowrey of The New York Times, Manu Raju of Politico. Let's go first to Glenn in Dallas, Texas. Hi, you're on the air.
GLENNHello, Diane. We love your show.
GLENNAnd it always makes us think, and we appreciate that.
REHMI appreciate your saying that.
GLENNI have, you know, a family member who is dependent on, you know, Medicaid and Social Security and those kinds of things. And, you know, it's somewhat kind of a system to me and to a lot of people that I know how the whole healthcare issue is fairing with Medicare and Social Security. And it's always told that, you know, it's an entitlement program, which it's not, because we paid that through our whole lives and, you know, it's not an entitlement.
GLENNIt's not like other programs that they call entitlement. And so many people that are dependent on it that, you know, how can they survive without it. And myself, I'm a cancer survivor, so with the new Obama healthcare plan -- program, I can't be denied insurance. So, you know, when you hit your home and hit you personally, then you really realize, you know, what goes on. And there are the people that are mainly against it are the ones who don't have to deal with it.
REHMHow right you are, Glenn. Thanks for calling. Annie?
LOWREYYeah. The term entitlement has become very politically loaded, even though it's just a technical term that refers to how these programs are financed in Washington and who has access to them. And it's a useful term for people who write about the budget. But I do think that it's become kind of this dirty word, which it seems to be what the caller was referring to.
RAJUI also think that the caller hits on a point that the Republicans have grappled with as they try to overhaul Medicare, is how to deal with current enrollees in the program or people who are about to get into the program. Because in the Paul Ryan plan, for instance, they say that, what they do with future enrollees, not ones who are in the program right now because they know the folks who say, we've been taxes in this program, we should get that coverage.
REHMHere are two emails both referring to the Oregon study. Ron in Alexandria, Va. says, "What reporters lost in talking about this story was that the ACF wants people to use the physician they are used to. Well, if you're poor, that physician was the hospital emergency room. They do not have the experience of going to the office of a private physician. Accordingly, the study is exactly the result one would expect." And here's a tweet from Martin: "The difference not being mentioned is that now ER visits will be paid for by the patients and not by raising rates on everyone else."
BENDAVIDYeah, it may suggest something about the way the incentives should be structured in these things. But I think this raises a very interesting point, which is you can't necessarily just pass a law, tell people they have certain kinds of coverage and expect their behavior to change right away. These are kind of deep cultural and behavioral approaches that people have taken to healthcare over their lives.
BENDAVIDAnd if somebody is used to going to the emergency room, they're not necessarily used to going to their annual checkup and doing all the correct preventive things that others are used to. And so I think this is going to take a little bit of time for it to kick in. And I think perhaps that's something that's been lost a little bit in the discussion.
REHMAll right, to Silver Lake, Ohio. Hi, Mark.
MARKHi, Diane. I'd like to address a myth that was spit out a little while ago when you were discussing the decriminalization of marijuana in Colorado. And that is the notion that the revenue stream, the tax revenue stream that it's creating right now will last. It will not. This is just a temporary tax level. And the reason it is, is that, as somebody in my mid-60s and the product of the '60s, I can assure you that marijuana is as easy to grow as the chives in your kitchen window.
MARKThere is nothing to grow in marijuana. And as the public gradually discovers how easy this is to grow, it's not like growing tobacco where you have to cure it and making the cigarettes and everything. This is nothing to grow. That revenue stream will vanish.
REHMSo what you're saying is people are going to grow it for themselves?
MARKNo question about it. And one plant is more than enough for personal use.
REHMOK. But don't you have to have a license to grow it?
BENDAVIDNo, actually in the Colorado law, I think you're allowed up to six plants that you can grow at home. So certainly that can be enough for personal consumption. And the caller is right. There may be way to circumvent that extra 25 percent tax. But, still, I think there's only a limited number of people that are going to do that. It may not be as hard to grow and cure as tobacco.
BENDAVIDAnd I do think we see the Netherlands. I mean, you know, perhaps the revenue stream will decrease a little bit, but it's hard for me to believe there's not going to be an ongoing source of people who are willing to go and buy marijuana at these stores.
LOWREYAnd I know, you know, chives are easy to grow, but I don't grow chives. I always buy them. There are a lot of people -- people are lazy.
RAJUAnd not to mention people out of state coming into Colorado.
REHMAll right. Let's go to Yael who's in New York City. Hi there.
YAELHi. Can you hear me OK?
YAELI like your show.
YAELHere's what I want to address in four quick sentences because I know you're busy. This is about Bill de Blasio, the new mayor of New York City. In a campaign promise to real estate moguls who spent hundreds of thousands of dollars on his campaign, de Blasio makes his first mandate in August to ban the Central Park horse and carriages. This will potentially put hundreds of horse owners, carriage drivers, grooms, stablemen, veterinarians, farriers and other handlers out of work, not to mention taking untold thousands of tourist dollars out of play.
SUEAnd I just want to say I know they're advertising some vintage electric car that would tour people through Central Park. But the truth is that that prototype is not even in existence yet and, for many reasons, impractical and not even feasible. So how does this move, banning horses from New York City, which is basically a land grab of the valuable stables on the far West Side across from the Java Center for de Blasio's real estate cronies -- and this seems to be diametrically at odds with income equality.
REHMAll right. Thanks for calling. Annie, what do you think?
LOWREYSo I hadn't heard the part about the land and the stables. I didn't know that. My understanding was that this is entirely about the welfare of the horses and that there are evidence that they're breathing these toxic fumes and that it's not the safest and best environment for them. I also know that the mayor's office has said that they will seek to find new jobs for all the people whose jobs would be lost. But I'm not sure about what will happen with the stables.
RAJUYeah. I mean, I think it speaks to the difficulty of a new mayor coming in with a very ambitious and heavy agenda, hoping that he can push things through, sort of, you know, kind of what we see time and again anytime a new president comes into office as well. You meet the reality, you meet the pushback from your voters and you meet right then maybe a resistant legislature or city council. So we'll see how that plays out.
REHMAll right. We promised to talk about some of the key congressional races all of us will be watching. What's at the top of your list, Naftali?
BENDAVIDI mean, I think you have to put Kentucky at the top of the list just because anytime there's a party leader, in this case Mitch McConnell who's engaged in a serious race not to mention a serious challenge from his own party, that's got to be a subject of interest. I mean, I'm not saying that eventually he won't prevail. He's a very strong, longtime, widely politician and he may well end up winning. But the fact is, he's going to have to spend a lot of resources.
BENDAVIDIt was a big deal when they went after Harry Reid. It was a really big deal when Tom Daschle lost. And I think that's got to be the marquee race. In part because he does face the Tea Party challenge internally and then a challenge from a fairly Democrat on the outside.
RAJUYeah, if McConnell loses, there's no chance Republicans win back the Senate. They have to win. And that of six seats to take back the Senate. They're probably going to win in open seats at Democratic-held seats in South Dakota, West Virginia, a favorite in Montana as well, those are three seats gone right there. Arkansas has a Democratic senator Mark Pryor, tough race. He could lose. Him and Mark Begich, the Alaska senator, Democratic senator also could lose.
RAJUThat's five seats right there. Then there are two other seats, Louisiana and North Carolina, Mary Landrieu and Kay Hagan, two other Democratic senators also in tough races. Republicans will have to run the table to win. But they also cannot have self-inflicted wounds as we've seen time and again. And that means these primary process that has produced candidates who are weakened or can't win in a general election.
RAJUThat threatens them again in North Carolina and in Georgia. If they lose those two seats because of the primaries or other reasons, they're not going to win the majority for this year and years to come.
LOWREYI think that when people are talking about 2014, unfortunately, now we're also talking about 2016 and how people are situating themselves within the parties. I think it's the most fascinating thing to watch. Of course, the Tea Party resurgence in the Republican Party, we've known about it for year -- we've been watching it for years. It continues to play out. But I think watching Democrats and who's positioning themselves to the left of the Obama administration is going to be absolutely fascinating.
REHMWhat about Wyoming, Naftali?
BENDAVIDWell, that's obviously a very interesting race because a daughter of a sort of major figure in the Republican Party, former Vice President Cheney is challenging a sitting Republican senator. That's a pretty unusual thing and obviously the subject of gay marriage has sort of erupted there. But also, you know, locally, Mike Enzi, the incumbent senator is fairly well-liked guy and sort of coming in both guns blazing.
BENDAVIDGoing after a guy who's been around a long time isn't necessarily being greeted in a positive way. But, you know, just to make a broader point, I'm sort of struck by how similar the landscape is to the last two elections. You know, a lot of vulnerable Democrats, but Republicans have to run the table but they're being threatened by Tea Party challengers within their own party. We've seen the last two elections. They haven't been able to overcome it. So whether either the party or the landscape has changed sufficiently for them to do better this time, I think it's going to be very interesting.
RAJUAnd that is why Republicans know they have to win this cycle because when you look at the map in future election cycles, in '16 and '18, it gets much, much more difficult for them to win the majority. They have to win it now. So they're taking a much more of the leadership, the Republican leadership is taking a much more combative approach to these outside groups. Groups like the Senate Conservatives Fund.
RAJUThey're spending a lot of money in these primaries. They're trying to defeat them and go after them in a much more aggressive fashion. Whereas in 2012, it kind of took a hands-off approach and let the primaries play out and that obviously didn't work.
REHMWhat does that mean for Tea Party candidates, Annie?
LOWREYWell, they continue to be very popular. This is the thing is that there's a sense that when they come to Washington, they throw some sand in the gears. You know, I think that there's a lot of folks who hold them responsible for the government shutdown. But that's when you actually get out into these races, they tend to do really, really well. And I think that a lot of that has to do with the underlying economic climate. And the fact they've managed to basically paint the rest of the party, in some cases as being crooked and not listening to the little guy.
RAJUYeah. I mean the Tea Party folks will, you know, I think they still have a good chance of winning in some of these primaries. I don't know of any sitting Republican senator is going to lose their primary this year. They seem to be all very well positioned. They have really built up a fund. They saw what happened to Dick Lugar in Indiana, Bob Bennett in Utah. And they don't want that to happen to them. They're well positioned.
RAJUThe only exception being potentially Lindsey Graham in South Carolina. He may be among the most vulnerable, maybe Thad Cochran in Mississippi but it seems the Republicans, at least the Republican senators are OK from those Tea Party threats.
REHMManu Raju of Politico, and you're listening to "The Diane Rehm Show." Let's go to Indianapolis. Good morning, Sue. How are you?
SUEGood, Diane. Love your show.
SUEMy comment is about people in, you know, that make the least amount of money of the food chain. People are not taught and they don't -- they're not comfortable with basic financial services. And they don't have budgeted in basic stop-gap measures. Being in the insurance pool and having everyone join this gigantic pool of, you know, that's what insurance is set up for. There's abuses of the system.
SUEThere's things in the system that need to be, you know, that insurance companies need to be held accountable for how they do business. And, you know, hospitals, the amount of money that it's spent just paying people to do billing, you know, there are flaws in the system. And I think on the front end, you are going to have people run to the emergency room with something when they first get insurance because they don't have a relationship with a doctor.
SUESo implement the whole thing. You know, make the doctors accessible to people so that they go in and get a physical or some kind of exam they haven't had for a while, you know, because my insurance policy didn't cover those things before. I'm self-employed and, you know, went through the Association of Realtors and got a temporary policy until I can really finish examining, like, what doctors take what insurance and really figure everything out.
SUESo there's a lot of time and effort that has to be spent to even digest the basic terminology for those consumers and they don't have the what if I get hurt and lost work for three months.
SUEAnd they don't have insurance. They're not spending the premium dollars to get the insurance to cover that on the...
REHMAll right, Sue, thanks for calling. Go ahead, Annie.
LOWREYOne thing that I think that the caller touched on which is true that the Oregon health study showed was that coverage really improves the financial situation of people who got it and compared to those who didn't. It makes them much less likely to go into medical debt, have a bankruptcy. That's kind of the essential function that insurance is supposed to play. One of the essential functions.
LOWREYAnd the study only looked at folks for two years. So there's nothing to say, you know, say, five years after you have Medicaid maybe at that point you understand you're not supposed to be going to the emergency room and instead you're supposed to be reaching out to your GP. And I can't really speak to how the system is going to respond to all these new pressure from all these new people getting covered.
LOWREYSo if hospitals or insurers themselves create stricter rules about who can go where and when or try to encourage people to go to sites of care that are a little less expensive, that could have a very profound effect.
BENDAVIDThe caller also raised this point that had to do with the need for educating people about the new law. To just throw this massive new program out there and expect people to figure it out is difficult. Democrats have said that Republicans are blocking some of the funding that they've tried to provide for education. Republicans see that as, I guess, propaganda or whatever. But I mean, that's a really central point that I think also shouldn't be overlooked.
RAJUYeah, that's right. And Naftali pointed this out earlier. This will require a substantial lifestyle change among a lot of the people in order to actually experience some of these benefits. People may not realize that things that they can do under this program. And that's going to take a long time in order for people to understand the extent of this program and the effects and the potential benefits.
REHMManu Raju, he's senior congressional reporter at Politico. Annie Lowrey is economic policy reporter for The New York Times. Naftali Bendavid, correspondent for The Wall Street Journal, currently based in Brussels just back for a visit. And we've been happy to have you.
BENDAVIDThanks for having me.
REHMCome back and see us again. Happy New Year, everybody.
BENDAVIDHappy New Year.
LOWREYHappy New Year.
REHMThank you and thanks for listening, all. I'm Diane Rehm.
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