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Anyone who has told you Medicare or Medicaid will not be cut by President Obama and the 113th Congress is wrong ... and is quite possibly also a Big Pharma CEO. Medicare and Medicaid are going to be cut, because that is exactly one thing Americans elected their leaders to do.

How can we be certain MC/MA will be cut? 17.6% is why.

The United States spends more on health care, both per capita and as a share of GDP, than any other country in the world. In 2009, spending on health care reached a record high $2.5 trillion, or 17.6 percent of U.S. GDP.
Massive reform of the US health care system has been a goal of progressive Americans and the Democratic Party for decades, if not for generations. Almost 20 years ago to the day Bill Clinton ran on it and won. He made it his first priority, and, 19 years ago to the day his reform effort was already dead and buried.

Four years ago President Obama and Congressional Democrats wrestled with Republicans over the Affordable Care Act. The ACA was fought for over the course of months. It finally passed by the skin of its teeth. It was immediately unpopular with the right, because it did something. It was unpopular with the left, because it did not do enough.

Now we approach 2013 with a big national Democratic victory in our pocket. Americans voted for Democrats ahead of Republicans despite the worst post-WW2 economy ever, despite ceaseless GOP obstructionism, despite Citizens United. Voters had the direct choice between Paul Ryan's Medicare elimination and Barack Obama's Medicare reform. Americans chose reform.

It's not 2011. It is almost 2013. Both the date and that Overton Window thing have moved. For the first time since LBJ's Great Society the American voter wants and expects major improvements to our nation's safety net. It is myopic to think that after all the years of hard work it took to arrive at this happy situation, that our political leaders will now casually throw it all away.

Myopic seems the apt term since some visions do not see past words such as "cuts", "pill", "bargain", or "compromise". Let us remind ourselves of something. 17.6% is roughly the same thing as one dollar our of every six going to health care. Buy a $5 sandwich from Subway and your next dollar goes towards an $11 aspirin pill down at the ER. We sent our candidates to Washington DC that they would cut down on that overhead.

Now that we have some ducks in a row a vocal minority balks at the chance. It's easy to understand why Big Pharma CEOs recoil in horror from the words cut, bargain, and compromise. Those of us who are not CEOs should look past those words to our goals. If ever there is a time to keep our eyes on the prize, certainly it's when our fingers begin to curl around the brass ring.

A few reasons why none of us should fear the word "cuts".


* We just went through a campaign during which the GOP attacked the ACA for "cutting $716 billion from Medicare". Most Americans concluded those "cuts" did nothing to undermine Medicare. We have 716,000,000,000 recent examples of why the word "cut" does not mean squat - but sure as shootin' the policy details do.

* G.W. Bush's Medicare Part D was deeply flawed as we recall. The ACA is closing the "donut hole", but Medicare still is not allowed to negotiate with Big Pharma on prescription prices. Negotiate, cut prescription costs, save money, save lives.

* For decades we have been hearing how Medicare's payment structure encourages excessive testing and over-treatment. Going to a payment structure designed around patient results has been proven internationally to reduce costs and improve outcomes. So let's cut that out.

* Every year we hear about the annual price adjustment battle waged in Congress. This is a totally artificial roadblock that causes a lot of ill-will and bad faith among health care providers. This might not be a major money-saver but cutting out this practice will produce a more affordable, stronger, more respected program.

* Home-based long-term / hospice care reform. Or safety net does not provide support for long-term care of our elderly until the family's net assets are down to under $2,000. Then Medicaid kicks in - for warehousing at a nursing home. There's no support for long-term care under the far cheaper and humane at-home option. Let's find ways to cut off corporate nursing home empires from the government trough.


In closing, Mr Trumka of the AFL/CIO has it right. Write our President and your Congressional representatives. Tell them you understand changes must be made. But be sure to tell them these changes must end up strengthening the social contract not undermining it.  As always hand-written letters or postcards get noticed much more than e-mails.

Do not forget we sent these people to Washington DC to make cuts to our health care costs. We want cuts. We need cuts to health care costs. Now when the election is over we are hearing our elected officials tell us they are poised to do much of what we have worked so long to achieve.

Let's not falter now over the word cuts! Our goal is not that of preventing all change to MC/MA. Change is in itself neither good nor evil. As always the devil is in the details. Tell your officials what you expect to see. And as always, don't panic.


It is possible to both cut MC/MA expenditures and strengthen the programs overall.

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Comment Preferences

  •  I am no expert, but I know a bit about home care (12+ / 0-)

    I took care of my incapacitated mother for about seven years, the last half with her bedridden. That was the outcome of a broken hip. Medicare paid for the hip surgery and the 'rehab' at a nursing home. The last time I saw her walk was at the hospital the day after her surgery. She walker a few steps from her bed to her wheelchair then, but after four months of nursing home 'therapy' she never walked again.

    When I tried to bring her home the nursing home threw every paperwork obstacle in my path to keep her inside and paying. At $275/day I spent almost 10 grand before I got her out. One physician made me wait 13 days for a meeting instead of giving me five minutes of phone time.

    Now that my mom has passed away, I have a closet shelf full of boxes of extra bandages, gauzes, wraps and the like. At MSR pricing I would not doubt it's "worth" over $1,000. This is just a small example of the casual waste in the system.

    I worked for a dozen years for a major health care manufacturer. How big? Decades later they still do business under the same name. So no, it was not Smith/Kline/Squibb/Johnson/Long John Silver's/Krups. Every year we'd have our state-of-the-corporation speech where we'd hear how profits were up the annual 20% the stockholders 'demanded'.

    Run 1.2 raised to the 20th power on your calculator and you'll see how this nation got to 17.6%.

    So let's get real. America can cut the hell out of her health care expenditures without reducing her health care quality. In fact, I'm pretty darn sure we're so far past the point of diminishing returns that cutting costs is a prerequisite to improvement.

    PS: (Please, if you are panicking over nothing more than a 2011 memo and/or the concept of small-d democratic compromise, do us all a favor and keep it to yourself. There's work to be done.)

  •  Cutting Medicare & Medicaid won't help (9+ / 0-)

    Doctors will refuse to take Medicare and Medicaid patients. Hospitals will find ways to avoid them. Hospitals that have a heavy load of Medicare and Medicaid patients won't be able to compete and will fail.

    Private insurance is where most of the bloat and inefficiency is. What fraction of the 17.6% is medicare & medicaid? What fraction of the highest cost patients are in medicare & medicaid?

    Moreover, our costs are high because we fail to deal with chronic problems until they result in expensive hospitalizations. We have lots of sick people that run up the costs because we don't give them the help that would keep them out of the hospital.

    You don't really understand why American health care is so expensive and so ineffective. We don't have a health care system. We have a disjointed mess. Your analysis is very superficial.

    look for my eSci diary series Thursday evening.

    by FishOutofWater on Fri Nov 16, 2012 at 06:46:03 AM PST

    •  Bull hooey - Docs will take what we give them (2+ / 0-)
      Recommended by:
      kalmoth, Quicklund

      We make the laws.

      Didn't you read the post?

      Are you with Romney and the $716 billion cut from Medicaire is too much? or the rest of us that see American has an out of control bloated system set up to enrich the 1%.

      How big is your personal carbon footprint?

      by ban nock on Fri Nov 16, 2012 at 06:56:45 AM PST

      [ Parent ]

      •  The problem is private insurance (9+ / 0-)

        And Medicare for all would have solved the 17.6% problem.  Going the other way will fail.  Spectacularly.  How do I know this?  Because no other country has managed to make our system work.

        •  not really, they are the problem (1+ / 0-)
          Recommended by:

          they only shift the costs to taxpayers and off the backs of other tax payers. Don't get me wrong, I like the redistributive affects but I don't like that there is no incentive to reduce costs.

          Single payer was the compromise and best left in the dustbin, we should be keeping our eyes on the ideal which is single provider. Take the profit out. No profit for fire fighting, police, libraries, health care.

          How big is your personal carbon footprint?

          by ban nock on Fri Nov 16, 2012 at 07:23:53 AM PST

          [ Parent ]

        •  Docs don't have to serve the old & the poor. (6+ / 0-)

          They can decide to take patients with insurance and not accept the rest. Med students can avoid going into residencies that serve the old and the poor.

          We have a shortage of physicians that is made up by docs working very long hours. They will cut their hours and work only for patients that pay if Medicare & Medicaid reimbursements are cut. Many docs don't take Medicare and Medicaid now because they do better without them.

          A lot of folks just don't get it.

          look for my eSci diary series Thursday evening.

          by FishOutofWater on Fri Nov 16, 2012 at 07:29:53 AM PST

          [ Parent ]

          •  This diary suggest cutting out that which MDs hate (0+ / 0-)

            When contemplating the effects of proposed changes ... one has to comprehend that changes have been made. That in turn means old assumptions are no longer valid.

        •  We are moving in that direction TJ (0+ / 0-)

          We didn't get there in one go. Not getting there in one go does not prove movement in the other direction.

        •  There are many models in other countries that (5+ / 0-)

          prove universal comprehensive medicare works. It means a healthier population, less chronic illness, more prevention. As a Canadian I can't even imagine the psychological torment of having to worry about medical bills on top of being sick.

          ❧To thine ownself be true

          by Agathena on Fri Nov 16, 2012 at 08:09:47 AM PST

          [ Parent ]

      •  It's not really the doctors who are milking the (5+ / 0-)

        system - it's the makers of medications, medical supplies, insurance companies, medical equipment, etc that are making things so expensive.

        I've seen where a ballpoint pen is labeled ergonomic in one package and labeled handicapped accessible.  The first would cost $2 and the second $5.  Why??  Because the company knows it can collect more because it's 'helping' handicapped people and insurance/medicare will pay it.

        There are sensible ways to cut medical expenses, not paying the doctors and their staffs isn't one of them.

        •  I didn't say not pay, and I didn't say staff (0+ / 0-)

          How about if we limit them when they are structured as a business? Why should I pay for third houses in the Caribbean with the health of my children in the balance?

          How big is your personal carbon footprint?

          by ban nock on Fri Nov 16, 2012 at 07:25:34 AM PST

          [ Parent ]

          •  I am a nurse and work with many hospitalists (3+ / 0-)

            and general practice doctors. The kind that we as a country need more of.  These Physicians do not have third houses in the Caribbean, not even close. They make a good living, but they also pay high insurance rates, they employ and pay a staff at their offices, and the more we make it uneconomical to accept medicare patients the more medicare patients will have to go to larger clinics where they receive less personal attention. Medicare needs to be able to pay an amount that fits the cost of a patient for the office/hospital.

      •  Docs will take private insurance (8+ / 0-)

        Hospitals and doctors who serve poor and old people will fail because the costs of serving those patients are high.

        Hospitals and docs that serve young people with insurance will do very well if Medicare and Medicaid cuts go ahead.

        Single payer and systemic restructuring to promote health are the solution, not cuts to services for the old and poor.

        I know this from the experience of trying to manage the business side of a solo medical practice.

        look for my eSci diary series Thursday evening.

        by FishOutofWater on Fri Nov 16, 2012 at 07:21:13 AM PST

        [ Parent ]

      •  Some docs (6+ / 0-)

        are ditching insurance altogether and taking cash only.  Some other docs are working on a concierge program, I think they call it, where patient pay a certain amount of money per month.  Subscriber program, essentially.

        No, not all doctors will just take what they are given.  That would only happen if there was no other option or if the supply of doctors was very high in comparison to demand. And that is NOT the case, nor has it ever been in my lifetime.  

        Some kinds of docs, family docs and internal medicine docs are already accepting a pittance based on negotiated contracts.  There are other specialists who get paid a ridiculous amount, but that's another story.  And many doctors will not just accept what Medicare or insurance pays, they will bill the patient for the  difference.  So the result will be that they
        1) stop accepting Medicare and Medicaid
        2) Bill the patient for the difference resulting in more medical debt or people sacrificing other essential needs to get care
        3) Bill the patient for the difference resulting in people not getting medical care because they can't afford it

        "Justice is a commodity"

        by joanneleon on Fri Nov 16, 2012 at 07:46:18 AM PST

        [ Parent ]

    •  Ridiculous (1+ / 0-)
      Recommended by:

      Patently ridiculous. At 17.6% of GDP there is more than enough dollars in the system right now to pay doctors a fine salary and still cut money from the system. And get this Fish: Medicare which deals with the eldery deals with the portion of the population which consumes the bulk of health care services. To suggest MC/MA has no impact on US Health care cost is delusional.

      My analysis is superficial? Yours boils down to "nothing can be done so despair".

  •  You left out two words (6+ / 0-)

    "Cuts to benefits."  Nobody voted for that.  Cost control, sure.  But trying to do that through Medicare will fail.

  •  I get the clever use of the word "cuts" (6+ / 0-)

    But a lot of people are still getting up to speed on this and might not get it. You're saying that costs will be cut, not benefits. Crucial to make this crystal clear.

    "Liberty without virtue would be no blessing to us" - Benjamin Rush, 1777

    by kovie on Fri Nov 16, 2012 at 07:05:18 AM PST

    •  If/when it happens (3+ / 0-)
      Recommended by:
      Agathena, tardis10, Brown Thrasher

      I think people will be able to discriminate between the two.

    •  This is the point I am working towards yes. (0+ / 0-)

      Somehow the simplistic notion has arisen that MC/MA are perfect systems that one dast never alter in the slightest. A moment's reflection should be enough to destroy that notion. If the system were perfect, why then have American progressives been so motivated for so long to change the system?

      The critics use the word "cuts" as though that proves Medicare is in the crosshairs to be destroyed or at best hollowed out. That's all they have, a word. Well that word is not a fact, it is a cup of tea leaves.

      •  The ARE in the crosshairs! (2+ / 0-)
        Recommended by:
        tardis10, Brown Thrasher

        Of Repubs and some Dems. Which is why it's a word we should avoid using, because it means two very different things to those who want to weaken and those who want to strengthen these programs. We should continue to call what the other side wants to do "cuts", and what we want to do "protect".

        "Liberty without virtue would be no blessing to us" - Benjamin Rush, 1777

        by kovie on Fri Nov 16, 2012 at 09:38:39 AM PST

        [ Parent ]

        •  Did you read any of the examples. Any? (0+ / 0-)

          I said in the crosshairs to be destroyed or hollowed out.

          Change does not equal destruction. If you oppose change then you are a champion for Big Pharma who wants to continue to name the price and hear Medicare respond with "We will pay". I am on the side of cutting those dollar out of Medicare and passing the saving on to Americans.

          Or goal is not to preserve MC/MA in amber. Our goal is to redesign these systems so the cost less and America gets better service.

          •  You've lost me (0+ / 0-)

            I'm now officially confused. Are we having an argument over semantics or actual substance? I'm opposed to benefit cuts, not cost cuts that won't hurt benefits. But when people hear cuts, they think the former and not just the latter. If we fight battles over words then we'll lose the war.

            "Liberty without virtue would be no blessing to us" - Benjamin Rush, 1777

            by kovie on Fri Nov 16, 2012 at 02:00:57 PM PST

            [ Parent ]

  •  Limiting Itemized Tax Deductions is a Ruse!!! (1+ / 0-)
    Recommended by:

    To allow the tax debate to be dictated by the losers tax plan (Mitt Romney's) the republicans are going to get their way and act as if they are creating a more fair taxing of the rich by saying (Eliminate the loopholes and limit the itemized tax deductions of the WEALTHY and broaden the tax base) = A ruse to not raise the marginal tax rate on people making $250,000 or more. And i'm afraid that Obama and the democrats we just elected have tried to open that door to try and look bipartisan.
       This is a serious mistake limiting tax deductions and broadening the tax base = GETTING MORE TAX REVENUE FROM THE MIDDLE CLASS. They throw in the word WEALTHY to complete the ruse.
       I f they don't do what we voted for ( Raise the marginal tax rate on $250,000 or more, make carried interest or capital gains to be taxed as regular income and take the cap off of Social Security to make it solvent for forever) The people we have just contributed to with money we don't have, canvassed for on time we could have  used for ourselves and voted for to win office. Will have effectively used us!!!!!!MARK MY WORDS!!!

  •  This is (4+ / 0-)


    We didn't elect people to cut Medicare and Medicaid.  An overwhelming percentage of Americans distinctly do not want to cut these programs.

    "Justice is a commodity"

    by joanneleon on Fri Nov 16, 2012 at 07:36:12 AM PST

  •  if my sister loses her funding (3+ / 0-)
    Recommended by:
    nchristine, TJ, Quicklund

    for her oxygen,she will die

    •  So that is the sort of thing that will not be cut (1+ / 0-)
      Recommended by:
      maybeeso in michigan

      There wass $2.5 trillion in the system in 2009. In 2013 that number is higher. The whole reason America has a health care crisis is because we pay too much for too little. Cutting money out of an over-paid system has been the point all along.

      Now that we have a chance to undo some of the wrongs after 50+ years of trying to reach this point, now is not the time to balk.

        •  How can we fix a broken system (1+ / 0-)
          Recommended by:

          by refusing to make changes?

          For decades our goal has been to reduce the grossly over-funded American health care bill. Now that we have the chance, why do you think the goal has suddenly become "prevent all change no matter what"?

          •  What your post seems to indicate is that (2+ / 0-)
            Recommended by:
            Quicklund, Brown Thrasher

            we pay the doctors less and don't pay for lots of test.  We're telling you that the doctors will not accept less for their services, period.  Yes, there are lots of tests that are being done that may not be necessary - that was started by the insurance companies wanting absolute proof of condition - get on the insurance companies for that one.  Yes, we need to have medicare negotiate with mega pharm to lower their charges and that will save the system money.

            So, then, do we not pay for MRI, PET scans, contrasts??  The charges by the hospitals/doctors are the result of the cost of the machines and the manufacturers 'need' for profits.  So, why penalize them for the cost of the exams when it's the manufacture that should be gone after??

            •  My diary indicates nothing ore than this (0+ / 0-)

              To say "Any cuts is wrong", is wrong.

              Where money is wasted or used inefficiently, those moneies should be cut out of the program. We should both expect this and welcome the development.

              That is not where the story ends of course. But this diary does not attempt to "fix" MC/MA. This diary exists to counter the notion that it is wise, 'liberal', or even possible to preserve MC/MA in unaltered form.

          •  And if my sister ends up (0+ / 0-)


  •  Well, a big-picture view (4+ / 0-)

    would admit the system itself is designed to bleed profit from human suffering. And that the necessary end goal - if there were politicians willing to pursue such a goal - would solve quite a few other problems at the same time.

    Universal single payer health care for all citizens cradle to grave would eliminate the need for Medicare and Medicaid altogether. Unshackling health care from employment not only helps our businesses compete in a world where universal health care is the norm, it also frees workers to pursue better jobs if they wish (or invent their own). Rather than spending more on our war-making machinery than the rest of the world combined, we could try being far less imperialistic and put the savings into infrastructure, energy independence and standard of living improvements (like universal health care) instead.

    APA is a good start, but it's going to need to expand dramatically and quickly if this nation wants to survive in the modern world.

    •  I agree. But that is not the issue before us today (1+ / 0-)
      Recommended by:
      maybeeso in michigan

      I am a proponent of single-payer/universal/national health care - whatever you want to call it. IMO we are moving towards such a model. We might even get all the way there.

      But that is not the issue before Congress right now. The issue before Congress now to raise revenues and cut expenses to the CPA's pronouncement that $4T will be saved over the next 10 years.

      That will be done partially by raising income taxes on the upper 2%. And if another portion is done by "cutting" out Medicare's inability to negotiate the price of prescriptions I for one will be cheering.

      •  Oh, I completely agree (0+ / 0-)

        that federal health care (all varieties) must be able to negotiate drug prices, even get patent wavers for single-supplier generics if Big Pharma refuses to negotiate.

        But that's not what the planned cuts to Medicare/Medicaid are all about, is it? As for SS - which the government borrowed against all these years - the U.S. Treasury can make good on our legally purchased T-Bills backed by the very same "full faith and credit" as anybody else's legally purchased investments. If they're going to stiff somebody, they need to stiff the rich rather than the poor. Why? ...because that's where the money is.

        40% on all sources of income at the top end of the scale wouldn't be too much. Eliminate all income level cut-offs for SS, Medicare/Medicaid taxes. Cut the military budget in half - close some bases overseas, end our several dirty big and little wars to steal other nations' natural resources, stop throwing good billions after bad on ridiculous weapons systems we don't need and can't be made to work even if they were needed.

        If we are the richest nation the world has ever seen, then let's re-prioritize so that we don't behave like a damned banana republic third world hellhole. Invest in us for a change. Free public education all the way through college or through trade/technical/professional certification. So that all our children get to make real contributions to the future. Stop giving subsidies and tax breaks to the biggest corporations, levy windfall profits taxes whenever their profit margin goes above a certain level. Get busy on rebuilding our grid, our transportation infrastructure, and our agricultural base. Develop and subsidize carbon-free energy sources, including transportation fuels (trains move freight quite efficiently at far less cost than a cross-country semi, though both of them could be using biodiesel instead of petroleum diesel). Provide real incentives and subsidies for the installation of solar panels on the roofs of homes, apartment and office buildings, strip malls, parking lots, mega-metal churches, factories and warehouses everywhere, wind wherever it's feasible. Put people to work in villages, small towns and cities across the country to build undershot hydropower generators along every 12-month flowing river. Go ahead and make use of the thousands of lakes created by the Corps during the Depression by replacing earthen dams with concrete and a spillway that turns a turbine. Start moving our low-lying oceanfront cities inland and uphill, secure their water-based infrastructure (shipping) with an eye to the fact that the water's rising.

        There's a lot we could do in this country if we weren't enslaved and forever-impoverished by greedy leftover robber barons who should have died off a hundred years ago. There's plenty of good ideas out here for actually producing needful things and serving actual people, if only all the money weren't tied up on the casino floor by oligarchs playing with Monopoly money and fake investments worth less even than the paper they're printed on.

        •  There are no planned cuts to MC/MA (1+ / 0-)
          Recommended by:

          Because there has not even been negotiation to write a plan. My motivation writing this diary is the large number of people worried sick about unspecific 'cuts'. Yet some tings we very much do want cut.

          You have a fine vision for moving forward. But given the limitations of human nature and cat herding, these projects will have to be won incrementally. Probably.

          Well I need to sleep.

    •  Medicare IS a single-payer program. (0+ / 0-)

      You don't know what you're talking about.

      •  Where did I suggest it's not? (0+ / 0-)

        Unfortunately, it only covers people 65 and older. I'm all for expanding it to everyone cradle to grave, though I somehow doubt they'll still call it Medicare. What they call it is irrelevant.

        If you want to get technical, Medicare in many states is actually administered by a burgeoning cadre of for-profit insurance companies, licensed by the government to offer 'plans' that only cover certain things. Florida was one of the testing grounds for this experiment, and it was a regular horror story whenever a patient's medical needs changed at an inconvenient time of year. If you got the drug plan you lost most of the hospitalization coverage. If you went for hospitalization (actual medical care coverage), you paid retail for prescriptions. My mother, dependent on a host of expensive medications for COPD, chose the drug plan. Then when she fell putting on her pajamas one night and broke her femur, hip, three vertebrae and both of her arms, she was SOL - hell, they wouldn't even set her arms, though she did get a new titanium hip (Medicare federal covers that), then got kicked out the next morning with no follow-up. No, she never walked again, or was able to use her arms. That's no way to run a health care system.

        Single-payer passed through for-profit administration doesn't guarantee any kind of decent health care at all, it's just another way for insurers to make money. It streamlines the paperwork and has power to negotiate prices. Those are  good things. But health insurance isn't the same thing as health care - that's a whole other beastie we have to deal with asap, since it kills 200,000 Americans every year who wouldn't have died if they hadn't checked into the hospital. How many it kills and maims who aren't in the hospital is not something anybody's keeping track of, because nobody really wants to know.

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