To the surprise of many, Nancy Pelosi and John Boehner quietly agreed to a proposed bill that would, among other things, permanently resolve the annual Medicare "doc fix" problem, fund such fix in part with a law requiring affluent Medicare beneficiaries to pay more, and fund two more years of the Childrens' Health Insurance Program (or, "CHIP").
The bill has been widely celebrated as a bipartisan victory of legislating. Still, people can't quite figure out what is up:
The new Medicare bill that the House passed on Thursday would weaken the program.
No, wait. The new Medicare bill that the House passed on Thursday would strengthen the program.
Many liberals believe the latter, while plenty of conservatives believe the former. Their shared faith in the bill -- for very different reasons -- helps explain why the House gave it such a huge bipartisan majority, why the Senate might pass it and why President Barack Obama has pledged to sign it.
Of course, the predictions from the right and the left can’t both be true. A bill that bolsters traditional Medicare can't simultaneously undermine it. But years will probably pass before we find out which side has guessed wrong.
The controversial part of the bill (unsurprisingly) comes from the Republican "ask":
One big lure for conservatives enthusiastic about the Boehner-Pelosi package is those higher payments from wealthier Medicare beneficiaries. The right’s long-term goal for Medicare is to privatize it -- by replacing the traditional government-run program with a voucher-like system, in which everybody would get some kind of “premium support” and then choose among competing private insurance options. Conservatives who support the bill believe that requiring more seniors to pay more of their own premiums would make such a transformation more likely.
You see, this proposed bill is an opening shot in what will become a long-term struggle. In particular, assuming Obamacare survives its political and legal challenges, the next looming policy fight will likely be:
will Obamacare gradually resemble Medicare-for-all, or will Medicare gradually become Obamacare-for-all?
Progressives long wanted Obamacare to include a public option, or a Medicare-for-all structure, that eliminates the insurance companies as middlemen. In agreeing to the current form of Obamacare, progressives still have hoped that over time the ACA would be forced to evolve towards a single-payer system. Under this view, once the right to universal health coverage has been established, the economic logic would move the ACA towards a single-payer system resembling Medicare.
Republicans, however, have advocated privatizing Medicare and replacing it with a system of privately available insurance subsidized in part with vouchers based on income need. Sound familiar? That roughly describes Obamacare. If Obamacare becomes entrenched, I predict Republicans eventually will embrace it and argue: "we have such a great system working with the ACA, and it makes no sense that we kick people off the ACA into government run insurance when they turn 65." At that point, we would have a cradle-to-grave mandated private insurance system, with subsidy amounts subject to political will. (It never ends.)
So there you have it. The "doc fix" and CHIP are all well and good, but the longer fight is whether we may have Medicare-for-all or Obamacare-for-all.
Does this mean that Democrats should oppose the Pelosi/Boehner bill? I can't say. Requiring higher co-payments from wealthier individuals is a form of progressive tax or user fee that liberals tend to favor. And, it is hard to fight every policy issue as if it is a vital battle in a conspiratorial ideological struggle. (That is why we are not Republicans.) On the other hand, FDR admittedly would counsel that means testing a universal social program is a path to its destruction. Maybe more damning, Krugman opposes the idea too.