By Peter Sullivan - 12-01-16 06:00 AM EST
The selection of Rep. Tom Price (R-Ga.) to become Health and Human Services secretary is testing President-elect Donald Trump's vow not to cut Medicare.
During the campaign, Trump said he stood out from other Republicans because he did not want to change the popular program.
"I'm not going to cut Social Security like every other Republican, and I'm not going to cut Medicare or Medicaid," Trump told the Daily Signal last year.
His campaign promoted the article's headline - "Why Donald Trump Won't Touch Your Entitlements" - on its website.
But Price does want to touch entitlements.
He is a proponent of a plan, also backed by Speaker Paul Ryan (R-Wis.), to turn Medicare into a "premium support" system, which Democrats warn would end the program's traditional guarantee of government-provided coverage for seniors.
Now that Price is set to head HHS, major changes to Medicare as well as Medicaid could be on the agenda - something Democrats fear would put big holes in the healthcare safety net.
Under a Medicare premium support system, seniors would get a set amount of money from the government to help them buy health insurance from a private insurance company, in contrast to the current government-run Medicare program.
Democrats say that because the whole idea of premium support is to save the government money, the government financial assistance would not keep up with rising healthcare costs over time, forcing more and more of the costs onto seniors.
They also suggest that costs could spiral out of control for the people remaining in the traditional Medicare program, which could remain an option, competing alongside private plans. Healthier people could be more likely to choose private plans, leaving the main program with sick people and higher costs.
Republicans counter that Medicare will eventually become insolvent and changes are needed to make it more efficient and save money.
"What we propose would ensure these programs have not just a future but a brighter one," Price said in a speech at the Heritage Foundation in 2014 in favor of premium support. "Reform is the avenue to improvement of services as much as a way to stave off fiscal collapse."
Democrats are already salivating over the prospect of Republicans seeking to upend Medicare, sensing a way to rally their party and gain political advantage.
"We say to our Republicans who want to privatize Medicare: Go try it, make our day," Sen. Charles Schumer (N.Y.), the incoming Democratic leader, said Tuesday, accusing the GOP of a "war on seniors."
Sen. Bernie Sanders (I-Vt.), meanwhile, tweeted an image of Trump's promise last year not to touch entitlements, including Medicare. Sanders asked if Trump "has any intention of keeping the promise that he made, or has he played the American people for suckers?"
Price and Ryan, though, have signaled that they are serious about going forward with changes to Medicare next year.
Price told reporters earlier this month that lawmakers could even use the fast-track process known as reconciliation to get a Medicare overhaul through the Senate with 50 votes, meaning it would not need Democratic support.
Senate Republicans, though, are less enthusiastic.
In contrast to ObamaCare, which Republicans in both chambers have openly called for repealing, Medicare changes engender caution among Senate Republicans.
Asked about a Medicare overhaul next year, Senate Majority Leader Mitch McConnell (R-Ky.) on Tuesday said, "I'm not going to speculate on what the agenda may be on a variety of different issues next year."
Vulnerable Senate Democrats are already signaling they could use Republican-backed changes to Medicare as a campaign issue.
Sen. Joe Donnelly (D), who faces reelection in 2018 in the red state of Indiana, was quick to oppose Price's nomination because he "led the charge to privatize Medicare."
Edwin Park, vice president for health policy at the liberal Center for Budget and Policy Priorities, said that since premium support is a way to save the government money, over time, "the federal government spends less; people have to spend more."
A major rationale for a premium support option is the idea that Medicare is running out of money, so changes have to be made.
Tricia Neuman, a Medicare expert at the Kaiser Family Foundation, said the program does have long-term challenges, mainly because of an aging population, but the issue is less urgent than it has been in the past.
"Medicare is in relatively good financial shape," she said, adding that it is projected to be solvent through 2028, a more distant date than has previously been projected.
Medicare spending growth is slowing, a change many experts attribute in part to reforms from ObamaCare, which set in motion many projects aimed at changing how Medicare pays for care.
However, Tom Miller, a healthcare expert at the conservative American Enterprise Institute, argued that a premium support system would allow private insurance plans to compete with the traditional system and see which is better.
"It sets the table for saying, if private plans do a better job, they'll get more people and offer better prices," Miller said. "Don't be afraid to find out what that answer is."
Some liberals are even more worried about Medicaid, the government healthcare program for low-income people, which generally has less political protection against cuts than Medicare.
Price and other Republicans have called for block grants to Medicaid, so instead of an open-ended federal commitment, states would have a set amount of funding to draw from.
Republicans say this would save money and give states more control, but Democrats warn that it would lead to cuts in benefits or caps on enrollment.
The potential sweep of the changes is massive. Twenty million Americans have gained coverage through ObamaCare, while 55 million people are enrolled in Medicare and 73 million people are in Medicaid.