The Medicare feud explained: both sides would cut but GOP more


Americans who don’t count themselves confused by the current debate over Medicare must be in the minority. Mitt Romney and Republican running mate Rep. Paul D. Ryan accused President Obama of hurting seniors by cutting $716 billion from the federal health program. The president retorts that the Republicans would “end Medicare as we know it.”

The truth is that both sides have plans that dramatically change the nearly half-century-old program. Seniors and seniors-to-be, as well as the disabled, are understandably anxious. Medicare has been widely popular because American working people appreciated its simplicity: They paid payroll deductions in and one day took out benefits that remained fairly predictable.

One of the best explanations of the differences between the two approaches that are now the subject of such furious debate has been offered by Trudy Lieberman, a veteran healthcare journalist who currently works for the Columbia Journalism Review. Lieberman’s most recent essay provides a long view of Medicare reform. She shows that both the Democrats’ “Obamacare” and the Republican plan embodied in Ryan’s “path to prosperity” budget would likely reduce benefits and increase costs for seniors — with the Ryan proposal of “premium supports” (more commonly known as vouchers) would more dramatically alter the status quo.


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One measure of just how dramatically the Ryan plan would change things, Lieberman reminds us, is that the Congressional Budget Office found that the Ryan proposal “would cut healthcare spending as a percentage of GDP from about 12% projected under current law to about 6% in 2030.” By Lieberman’s assessment, that would be “huge.” And the Ryan plan effectively has become the Republican plan. After some initial hedging, presumptive Republican nominee Romney called his running mate’s plan “close to identical” to his own.

The Ryan proposal would leave the Medicare entitlement in place for those already 55 and older. For those who reach retirement age later it would offer the alternative of vouchers — a fixed amount of money annually that beneficiaries could use to buy health insurance in the private market. Reporter Lieberman notes that if the vouchers didn’t cover all the medical care that seniors want, they would pay the difference out-of-pocket. Some Medicare experts believe the vouchers wouldn’t keep up with the rate of inflation. The Congressional Budget Office found that under the Ryan plan, “most elderly people who would be entitled to premium support payments would pay more for their healthcare than they would pay under the current Medicare system.”

What about the Republican ticket’s claim that those already receiving Medicare benefits would not see any change? With the adoption of a voucher program, experts said, this is far from clear. The reason is that younger, healthier and wealthier individuals would be expected to opt out of the traditional Medicare pool. This would put tremendous pressure on the already struggling Medicare trust fund by leaving mostly the sickest, costliest patients behind. The outcome would likely be higher Medicare premiums for those who remained in the plan, Lieberman reported.

The journalist sees another challenge that would be presented if Medicare were to be divided into two parts. “We have broken this bond that has been a part of Medicare since 1965,“ Lieberman said in an interview. “People have known they would pay in and also receive benefits out. That would go away.”

The proposed Republican changes cannot be compared to some benign status quo. Obama’s Affordable Care Act also embraces the notion that seniors should pay more. The law requires that, beginning in 2015, so-called Medigap policies (known as plans F and C) that seniors buy to get additional services leave some out-of-pocket costs to be paid by every beneficiary. Seniors should pay part of their medical bills directly, the theory goes, to push them to be more attentive about controlling their healthcare expenses. They would, the medically insensitive expression goes, have more “skin” in the game.

Other increased charges are coming down the road, under the Obama health law. The act already requires an additional premium for seniors at the upper 5% of the income spectrum for things like doctor’s office visits and lab tests, Lieberman explained. And both political parties have expressed support for eventually increasing the percentage of seniors who pay those higher Medicare premiums.

The Republicans have tried to seize the initiative on the Medicare question in recent days by saying that Obama has even more dramatic cuts in store -- $716 billion, they say, over a decade. Those reductions would be real. But what Romney and Ryan have not made clear is what would be cut. About four-fifths of the reductions would be taken in the form of reduced reimbursements to health insurers, hospitals and home healthcare workers. About $156 billion would be cut from Medicare Advantage. That program provides additional coverage for more than 10 million Americans who pay an extra premium for things like additional dental and chiropractic service.

The reduced government support for Medicare Advantage will doubtless upset some seniors who enjoy the extra services. But when he was a candidate, Obama vowed to reduce the extra coverage for some in order to prolong the health of the Medicare Trust Fund, which serves everyone. The savings from those reductions are expected to keep the trust fund out of the red for an additional eight years — staving off deficits from 2016 until 2024.

Republicans may find it a bit uncomfortable to sustain attacks on Obama’s $716 billion reduction, though. It turns out that Ryan’s budget proposal included the same maneuver. Romney’s claim that he would restore that $716 billion leaves unclear how he would maintain the system’s solvency.

Confused? That would not be surprising, given the furious rounds of charge and countercharge.

And we haven’t even started talking about Medicare’s less popular cousin (at least with most taxpayers) -- Medicaid. That federal health plan provides insurance mostly for the poor. The welfare program tends to have less public support and, therefore, to be even more subject to cuts by the feds and the states, who administer the program.

Ryan’s proposal calls for paying “block grants” to the states to provide health insurance for the poor. The Congressional Budget Office projected that the block grant payments would likely decrease coverage for recipients, doctors and hospitals. States, the CBO found, would probably therefore reduce the ranks of those eligible for coverage. Obama’s health law, meanwhile, envisions adding 17 million beneficiaries to the Medicaid roles.

Lieberman writes for a journal followed most closely by journalists. She has been urging for years that reporters give closer scrutiny to all the proposals. The reporter concluded her most recent report with an admonition that journalists track how the “ ‘reforms’ affect ordinary people.”

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