Elec­tion’s se­nior mo­ments

Can­di­dates lob Medi­care charges de­spite small odds of big changes in 2015

Modern Healthcare - - NEWS - By Paul Demko

Demo­cratic Se­nate can­di­date Ali­son Lun­der­gan Grimes, who is chal­leng­ing Se­nate Mi­nor­ity Leader Mitch McCon­nell in Ken­tucky, re­peat­edly has sidestepped ques­tions about whether she would have voted for the Pa­tient Pro­tec­tion and Af­ford­able Care Act.

But the Grimes’ cam­paign last month re­leased a 60-sec­ond TV ad fea­tur­ing her grand­mother dis­cussing the de­bil­i­tat­ing ef­fects of her hus­band’s stroke.

Grimes ap­pears and says: “This is why we have to strengthen Medi­care. Sen. McCon­nell’s voted over and over again to raise se­niors’ Medi­care costs. I’ll never do that.”

Medi­care is sur­fac­ing of­ten in at­tack ads like this in the fi­nal cam­paign push lead­ing up to the Nov. 4 con­gres­sional elec­tions. In re­cent weeks, it also has been the sub­ject of ads in tight Se­nate con­tests in Alaska, Arkansas, Iowa and Louisiana. Those are among the races that will de­ter­mine which party con­trols the Se­nate in 2015—and how much power con­gres­sional Repub­li­cans will have in wran­gling with the Obama ad­min­is­tra­tion over the ACA and other health­care is­sues.

But many ex­perts ques­tion whether ei­ther party will se­ri­ously pur­sue ma­jor changes in the popular pro­gram after the elec­tion, no mat­ter who con­trols the Se­nate. The end­less war over Oba­macare has dis­cour­aged many elected of­fi­cials from tak­ing on another bloody health­care fight. Most ob­servers don’t ex­pect that to change after Elec­tion Day, even though many Repub­li­cans see pri­va­tiz­ing Medi­care and cap­ping its spend­ing as cen­tral to their agenda.

“I just can’t imag­ine that Congress will want to get into the re­ally con­tro­ver­sial stuff,” said John Rother, a for­mer se­nior AARP of­fi­cial and cur­rent pres­i­dent of the Na­tional Coali­tion on Health Care, a non­par­ti­san ad­vo­cacy group. “That sense of ur­gency that we have to do some­thing to keep the pro­gram alive is not nearly as in­tense as be­fore.”

Over the past sev­eral years, con­gres­sional Repub­li­cans, led by House Bud­get Com­mit­tee Chair­man Paul Ryan of Wis­con­sin, re­peat­edly have pro­posed ma­jor struc­tural changes in Medi­care, in­clud­ing pay­ing se­niors a fixed amount to se­lect among pri­vate plans or tra­di­tional Medi­care, rais­ing the el­i­gi­bil­ity age and charg­ing higher means-tested pre­mi­ums.

Pres­i­dent Barack Obama’s most re­cent bud­get pro­posal in­cluded more than $400 bil­lion in re­duced spend­ing on Medi­care over a decade. That in­cluded $53 bil­lion in in­creased pre­mi­ums for higher-in­come ben­e­fi­cia­ries and $117 bil­lion from re­quir­ing drug­mak­ers to give re­bates on pre­scrip­tion drugs to low-in­come ben­e­fi­cia­ries on Medi­care and Med­i­caid.

In ad­di­tion, var­i­ous groups and ex­perts have pro­posed other changes such as re­vamp­ing ben­e­fi­ciary cost­shar­ing and the rules for sup­ple­men­tal

cov­er­age, ex­pand­ing com­pet­i­tive bid­ding and al­low­ing the CMS to ne­go­ti­ate lower drug prices.

While a ma­jor over­haul of Medi­care looks un­likely in 2015, there are ar­eas of pos­si­ble ac­tion. If Democrats re­tain con­trol of the Se­nate, Rother pre­dicts Se­nate Fi­nance Com­mit­tee chair­man Ron Wy­den (D-Ore.) will push dur­ing the lame-duck ses­sion for per­ma­nent re­peal and re­place­ment of the Medi­care sus­tain­able growth-rate physi­cian pay for­mula. In March, Congress passed a one-year patch—the 17th straight short­term fix—to avoid sig­nif­i­cant de­creases in physi­cian pay­ments.

But oth­ers are skep­ti­cal, par­tic­u­larly given the dif­fi­culty in get­ting bi­par­ti­san agree­ment on how to pay for the ex­pen­sive fix. “That seems un­likely,” said Dr. Mark McClel­lan, who served as CMS ad­min­is­tra­tor un­der Pres­i­dent George W. Bush and is now a se­nior fel­low at the Brook­ings In­sti­tu­tion. “It’s tough to get big leg­is­la­tion done in a lame-duck ses­sion.”

Even if the Repub­li­cans win the Se­nate, McClel­lan doubts Congress will be able to push through ma­jor Medi­care changes such as Ryan’s pro­posed “pre­mium support” plan as long as Obama is pres­i­dent. Still, McClel­lan thinks there could be a few sig­nif­i­cant changes, such as ex­pand­ing the Medi­care ac­count­able care and bun­dled pay­ment ini­tia­tives and in­creas­ing means test­ing of Medi­care pre­mi­ums. “Even if you don’t get all the way to the Ryan plan, there’s a good op­por­tu­nity for Repub­li­cans to make in­cre­men­tal progress in that di­rec­tion,” McClel­lan said.

Another pos­si­ble area of bi­par­ti­san agree­ment if Democrats re­tain Se­nate con­trol is Wy­den’s Bet­ter Care, Lower Cost Act, co-spon­sored by Sen. Johnny Isak­son (R-Ga.). That pro­posal aims to save money by bet­ter co­or­di­nat­ing care for Medi­care ben­e­fi­cia­ries with mul­ti­ple chronic con­di­tions. The bill has bi­par­ti­san support in the House.

A big fac­tor driv­ing more sweep­ing Medi­care over­haul pro­pos­als has been the rapidly ris­ing cost of the Medi­care pro­gram. But now, while the pro­gram faces long-term fis­cal prob­lems be­cause of a huge num­ber of baby boomers who are surg­ing into it, per capita spend­ing growth has slowed sig­nif­i­cantly, less­en­ing the pres­sure to take ac­tion. Per-ben­e­fi­ciary spend­ing grew by 0.3% in 2012 and was flat in 2013, ac­cord­ing to the 2014 Medi­care Trus­tees’ re­port. The Part A hos­pi­tal trust fund now is ex­pected to re­main sol­vent through 2030—13 years longer than

Over the past sev­eral years, con­gres­sional Repub­li­cans, led by House Bud­get Com­mit­tee Chair­man Paul Ryan, re­peat­edly have pro­posed ma­jor struc­tural changes in Medi­care.

be­fore the ACA was passed.

De­spite the im­prob­a­bil­ity of a Medi­care over­haul after the elec­tion, con­gres­sional can­di­dates are in­vok­ing Medi­care as an is­sue this fall be­cause se­niors make up a dis­pro­por­tion­ate share of the vot­ers in mid-term elec­tions when over­all turnout is low.

“It’s a midterm, (so) you’re talk­ing to 50-plus vot­ers,” said Jim Cauley, a Ken­tucky po­lit­i­cal oper­a­tive who ran Demo­cratic Gov. Steve Bes­hear’s

gu­ber­na­to­rial cam­paign in 2007. “Medi­care af­fects their lives.”

Democrats are us­ing Medi­care as a cam­paign is­sue more ag­gres­sively than Repub­li­cans, a con­trast with the 2010 elec­tions when Repub­li­cans had suc­cess blast­ing Democrats for sup­port­ing the ACA’s Medi­care spend­ing curbs. In the first half of Septem­ber, one in five Demo­cratic ads men­tioned Medi­care or So­cial Se­cu­rity, ac­cord­ing to Kan­tar Me­dia CMAG, a non­par­ti­san me­dia mon­i­tor­ing or­ga­ni­za­tion. By com­par­i­son, just one in 10 GOP ads men­tioned the se­nior pro­grams.

But some ob­servers ques­tion the ef­fec­tive­ness of some of the ads. Stephen Voss, a po­lit­i­cal sci­ence pro­fes­sor at the Univer­sity of Ken­tucky, said Grimes’ ad with her grand­mother was a dud. “That par­tic­u­lar ad re­ally shows the lim­its of try­ing to make co­her­ent po­lit­i­cal ar­gu­ments in one minute,” he said.

In re­cent elec­tions, Repub­li­cans have had the up­per hand with se­nior vot­ers. Pres­i­den­tial can­di­date Mitt Rom­ney re­ceived support from 56% of vot­ers age 65 and older in 2012, up from 53% for John McCain in 2008. In 2010, which saw Repub­li­cans win 63 House seats and con­trol of the cham­ber, 59% of se­niors backed GOP House can­di­dates, ac­cord­ing to CNN.

There are some in­di­ca­tions, how­ever, that Democrats are do­ing bet­ter with se­niors this time around. A Kaiser Health Track­ing poll con­ducted in Au­gust and Septem­ber found that regis­tered vot­ers 65 and older were evenly split over whether Democrats should keep con­trol of the Se­nate, although Repub­li­cans held a five-point edge among likely vot­ers. Some ob­servers at­tribute the ap­par­ent Demo­cratic gains to older vot­ers be­com­ing in­creas­ingly skep­ti­cal about per­sis­tent Repub­li­can claims that Oba­macare’s Medi­care spend­ing cuts have hurt their ben­e­fits.

Nev­er­the­less, Repub­li­cans have res­ur­rected that line of at­tack in re­cent TV ads in Arkansas, Ge­or­gia and Iowa. Un­der the ACA, Medi­care spend­ing is pro­jected to de­cline by $716 bil­lion over 10 years, ac­cord­ing to the Con­gres­sional Bud­get Of­fice. But those cuts re­duce pay­ments to Medi­care Ad­van­tage in­sur­ers and health­care providers, while the law ac­tu­ally en­hanced ben­e­fi­cia­ries’ cov­er­age for drugs and pre­ven­tive ser­vices.

Another prob­lem with the GOP at­tacks is that con­gres­sional Repub­li­cans also ad­vo­cate cut­ting Medi­care spend­ing. House Repub­li­cans have in­cluded those same Medi­care spend­ing re­duc­tions to im­prove the pro­gram’s fi­nances and re­duce the fed­eral bud­get deficit. Robert Mof­fit, a se­nior fel­low at the con­ser­va­tive Her­itage Foun­da­tion, ar­gues that such cuts are nec­es­sary. “One thing is ab­so­lutely cer­tain: You are look­ing at huge de­mo­graphic pres­sures which are go­ing to be hit­ting Medi­care in the next five years,” he said.

“Don’t change their pro­gram”

But the mis­lead­ing na­ture of the GOP charge might not dull its ef­fec­tive­ness as a cam­paign weapon. “Many older peo­ple aren’t clear what the ACA did or didn’t do,” said Robert Blen­don, a Har­vard Univer­sity ex­pert on pub­lic at­ti­tudes about health­care. “They just want to be sure you don’t change their pro­gram. It will mat­ter to them if they think one party or the other is go­ing to do some­thing neg­a­tive to Medi­care or So­cial Se­cu­rity.”

In their Medi­care at­tacks, Democrats also fo­cus on Ryan’s pro­posal to move fu­ture Medi­care ben­e­fi­cia­ries into pri­vate plans un­der a de­fined con­tri­bu­tion model, po­ten­tially ex­pos­ing se­niors to higher out-of-pocket costs. But in the crude par­lance of cam­paign ads, the sub­tleties of Ryan’s pro­posal are lost.

Rep. Ron Bar­ber (D-Ariz.), fac­ing off against Repub­li­can can­di­date Martha McSally whom he beat by less than 700 votes two years ago, claims in an ad that McSally would “cut Medi­care to cut taxes for mil­lion­aires.”

That’s based on McSally’s support for Ryan’s House bud­get blue­print, which would cut taxes for high­er­in­come Americans. The Na­tional Repub­li­can Con­gres­sional Com­mit­tee has coun­tered with an ad ac­cus­ing Bar­ber of sell­ing out se­niors. The ev­i­dence: $716 bil­lion in Medi­care cuts un­der Oba­macare.

Last month, Democrats held a rally on Capi­tol Hill to raise alarms about the GOP agenda on Medi­care and So­cial Se­cu­rity. Dozens of se­niors af­fil­i­ated with la­bor unions waved signs that read: “Tell the Tea Party: Hands Off My Medi­care” —mir­ror­ing signs from Tea Party ral­lies against the Af­ford­able Care Act in 2009. A pa­rade of Demo­cratic leg­isla­tive lead­ers, union of­fi­cials and House mem­bers fac­ing tough re-elec­tion cam­paigns took turns speak­ing.

Rep. Rick Nolan (D-Minn.), whose re-elec­tion contest is deemed a “tossup” by the Cook Po­lit­i­cal Re­port, told the crowd: “They want to turn

A big fac­tor driv­ing more sweep­ing Medi­care over­haul pro­pos­als has been the rapidly ris­ing cost of the Medi­care pro­gram.

Medi­care back over to the in­surance com­pa­nies. We can­not let them do that.” He was fol­lowed by Rep. Joe Gar­cia (D-Fla.), another in­cum­bent in a tight race. “I will never vote to cut Medi­care, pe­riod,” Gar­cia said.

Arthur San­ders, a po­lit­i­cal sci­ence pro­fes­sor at Drake Univer­sity in Des Moines, Iowa, said the stock Medi­care at­tacks block le­git­i­mate de­bate about how to se­cure the fu­ture of Medi­care. “The de­mo­graph­ics tell us that we’re go­ing to have to do some­thing,” he said. “Things would work bet­ter if we could ac­tu­ally dis­cuss it in an adult­like way in a cam­paign.”

Democrats ral­lied re­tirees last month on Capi­tol Hill seek­ing to raise fears about Repub­li­cans’ Medi­care agenda.

Demo­cratic Ken­tucky Se­nate can­di­date Ali­son Lun­der­gan Grimes, cen­ter, ac­cused

her op­po­nent of re­peat­edly vot­ing to cut Medi­care. The ad fea­tures Grimes’

grand­mother talk­ing about her hus­band’s stroke.

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