By Alexander Bolton - 01-01-17 10:30 AM EST
Senate and House Republicans are headed for a clash over whether to tackle Medicare reform under President-elect Donald Trump.
Senate Republican leaders prefer to focus narrowly on an ObamaCare replacement bill that does not contain changes to Medicare - a cautious approach that reflects their slim majority.
But House Republicans, firmly in control of the lower chamber, want to aim higher. They say unified Republican control of government is a chance to finally enact the entitlement reforms that they've been talking about for years.
Rep. Pete Roskam (R-Ill.), a member of the Ways and Means Committee, which has jurisdiction over healthcare, said voters have endorsed the Republican argument that Medicare needs to be reformed.
"The changes in Medicare that we have proposed have been litigated and the country has said, we'll entrust you with very big majorities," Roskam said. "Republicans keep talking about these things and keep winning. The question isn't whether to do them, it's when to do them."
The wild card in the debate is Trump.
He pledged during the campaign not to cut Medicare, Medicaid or Social Security, but his Cabinet selections have cast doubt on that promise.
House Budget Committee Chairman Tom Price (R-Ga.), whom Trump tapped to serve as secretary of Health and Human Services, is a leading advocate of Medicare reform, as is Rep. Mick Mulvaney (R-S.C.), his choice to head the White House budget office.
Speaker Paul Ryan (R-Wis.) said shortly after the election that Medicare and Medicaid would have to be reformed to some extent as part of the effort to replace ObamaCare.
"ObamaCare rewrote Medicare, rewrote Medicaid, so if you're going to repeal and replace ObamaCare, you have to address those issues as well," Ryan told Fox News.
"Because of ObamaCare, Medicaid is in fiscal straights," Ryan added. "Medicare has got some serious problems because of ObamaCare. Those things are part of our plan to replace ObamaCare."
Ryan said this month during an appearance on CBS's "60 Minutes" that Medicare "goes bankrupt in about 10 years" and warned "the more we kick the can down the road, the more we delay, the worse it gets."
Ryan's "Better Way" plan calls for repealing "the most damaging Medicare provisions contained in ObamaCare" and adopting "bipartisan reforms that make Medicare more responsive to patients' needs" while also "updating payment systems that are outdated and inefficient."
Ultimately, many Republicans would like to transform Medicare from a fee-for-service program that provides virtually unlimited coverage to one where the government contribution per patient is more fixed. Under such a system, the thinking goes, beneficiaries would have more incentive to control their medical cost.
Ryan has championed the idea of premium support, under which Medicare would be an option for seniors alongside plans from private insurers. The competition could save money in markets where consumers have a wide array of options.
Other possible reforms that the GOP could pursue include raising the Medicare retirement age and implementing means testing, which could limit benefits for wealthier people or charge them extra fees.
Price, before he was picked by Trump to oversee federal healthcare programs, told reporters that House leaders would pursue Medicare reform in 2017.
He predicted a reform bill would protected by special budgetary protections known as reconciliation that prevents Senate filibusters, but did not say whether the Medicare changes would be part of the same package to replace ObamaCare.
Republicans pushing for action on Medicare say the next Congress, which convenes in January, might be their best opportunity to overhaul Medicare before it hits a funding shortfall in 2028.
"It's inextricably linked from the textbook standpoint. It's something that ought to be done," Rep. Mark Sanford (R-S.C.), a member of the Budget Committee, said of replacing ObamaCare and reforming Medicare.
But Sanford questioned whether some of his colleagues would be willing to face the political risk that comes with changing Medicare.
From a political standpoint, it probably won't be [linked] because it involves hard lifting that brings with it real pain that's not politically popular," Sanford added.
The appetite in the House to go big reflects their safer majority. They will control 241 seats next year, compared to 194 for Democrats - a huge margin that would likely require a wave election to reverse.
Senate Republicans, who will have 52 seats compared to the Democrats' 48, have more to worry about in the 2018 midterms. They're slamming the door on talk of linking Medicare reform to the ObamaCare replacement bill.
Senate Republican Policy Committee Chairman John Barrasso (Wyo.), a doctor and the leadership's expert on healthcare issues, said the funding shortfall is Medicare is a "tidal wave" facing policy makers because "10,000 Baby Boomers turn Medicare-age every day."
"We need to have the discussion, but I don't think that it should be part of the repeal and replacement of ObamaCare," he said.
Senate Health Committee Chairman Lamar Alexander (R-Tenn.) has the same view.
He warns Republicans should be careful about "biting off more than you can chew."
Replacing ObamaCare with what his party hopes will be a system that offers more choices and lower costs, "is a lot to get done and will take all of our best efforts," Alexander said.
"We should put the solvency of Medicare aside for another day."
When Congress passed ObamaCare in 2009, Republicans criticized Democrats for expanding the social safety net without doing enough shore up Medicare, a program headed toward insolvency.
Ryan still sees that as one of the major flaws of ObamaCare, according to Rep. Pat Tiberi (R-Ohio), a senior member of the Ways and Means Committee.
"I think the Speaker would agree with that today," he said.
Democrats counter that the GOP's drive to repeal ObamaCare will only make Medicare's problems worse. They point to trustees reports that state that the healthcare law extended the life of the Medicare trust fund by 12 years.
The question now facing Republicans is whether they want to create a new system to replace ObamaCare without addressing Medicare.
"There's tension on both sides of the answer," said Rep. Michael Conaway (R-Texas). "The things we will do in lieu of ObamaCare will be difficult.
"Do you bite off too much trying to tackle both at the same time?" he asked, expressing skepticism that Congress could accomplish too herculean tasks simultaneously."
At the same time, he noted, "We have to renegotiate Medicare."
"If we can do them both at the same time that would be great because the sooner we get Medicare done, the less draconian the changes will have to be," he added.