Over the weekend, I watched Twitter as drops of information about the debt ceiling leaked out bit by bit. There was a deal. No deal. Well, maybe a deal. The deal would require Congress to wait until a Balanced Budget Amendment passed in the states before it acted. Well, no it actually didn't include that. Medicare was on the chopping block. Well, not cuts to members, only cuts to physicians and other providers. What's an ordinary person to think?
There was plenty of humiliation to go around. Speaker Boehner didn't return the president's phone calls. Speaker Boehner couldn't rally his own party to support his deal. Majority Leader Reid couldn't get Republicans to talk to him. Sen. McConnell would only talk to Biden not Reid, and his unfortunate facial expressions left us with the impression that he had a serious digestive problem. The classic picture was Boehner in the House elevator letting out a long groan as the doors closed. He was not the only one groaning.
Pundits made the worst cliché pronouncements. Everything was a "crisis"; there was lots of "kicking the can down the road." TV time had to be filled and fill it they did. Those smart folks who spent the weekend outside, barbecuing or swimming, were the wise ones. We all knew it would come down to the last moment, but oh, was it painful to watch those last agonizing hours.
Now that the debt ceiling will be raised and we can pay our bills (for a while at least), we are left to wonder -- what will it really mean for some of the programs we care about? The predictions have ranged from death to resurrection for Medicare and Medicaid. But somewhere in this pile of doo-doo there may be a few ponies. The details of the debt ceiling "deal" require that some programs be kept off the table in the negotiations of the "super committee." Those programs include Medicaid (remember almost half of Medicaid goes to nursing home care and the rest to health benefits for the disabled, poor women and children, and the elderly), Social Security, military salaries, and veterans' benefits. Cuts to Medicare cannot affect "benefits" (although the committee can raise eligibility age and potentially copayments), only payments to providers. The military and Homeland Security are not exempt as they have been in the past.
While there is some protection for the programs that serve our most vulnerable citizens, it is hard to claim that these are victories we should cheer about. Some of the key aspects of the health reform law may be affected negatively by the need to make these deep budget cuts. Funding for the subsidies that will allow people of limited income to get health insurance in 2014 may be severely constrained. The new Independent Payment Advisory Board (IPAB), which has been under fire for some time, may be eliminated, leaving decisions about how to contain costs in Medicare to the politicians -- the same politicians that have proven themselves unable to do that very thing up to this point. While many of the health reform law's provisions are already being implemented (e.g. closing of the donut hole in prescription drug coverage for seniors, allowing young adults to stay on their parents' plan until 26, tax credits for small business to help them provide coverage, the establishment of state-based exchanges, demonstration programs to cut costs and maintain quality in Medicare -- to name a few things), the full roll out of the law very much depends on who wins what in 2012. If the Republicans keep the House, win the Senate and the Presidency, the ACA will most definitely be repealed.
Meanwhile? There is no Republican plan to fix health care, other than Rep. Ryan's proposal to give seniors some money and toss them into the health insurance marketplace to find coverage. Oh yes, and more "personal responsibility" for health care, translated as shifting costs to us and requiring us to try to figure out which doctor or hospital is cheaper and better, when that is almost impossible to do with the information we currently have. The trifecta of Republican options remains the same: 1) personal responsibility 2) malpractice reform and 3) selling insurance across state lines. Have these solutions brought down health care costs? Not so much.
I am generally a pretty optimistic person. If you read my blogs, you know that I try to find something positive in almost every aspect of health reform, even though many of you have tried to disavow me of that optimism and have accused me of pollyanism or worse! Still, I have found plenty of ponies in the last several years -- the bookstore owner who was able to give her employees coverage because of the tax credit; the family whose son had cancer but could keep him on their insurance plan while he underwent chemotherapy; the savings for seniors from the closing of the donut hole for prescription drugs; the state programs for people who are uninsurable.
What I tell my family and friends now is the following: 1) This is not the worst deal ever. There are some wins for health care programs and some small potential for meaningful tax reform. 2) If you care about keeping Medicare and Social Security solvent you need to speak out and organize, but also be willing to be flexible about what changes to those programs will keep them solvent and 3) While you may not think that the president negotiated as well as he could have, we don't really know all the details and the background of what went down. I do think it could have been worse and so do many others.