The Stealth Assault on Medicare -- Robert Kuttner, The American Prospect

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https://prospect.org/blogs-and-newsletters/tap/2025-09-19-medicare-budget-republicans-democrats-affordable-care-act/

Democrats are making a budget stand over Trump’s cuts to Medicaid and the Affordable Care Act. But Trump is also coming for the much larger Medicare program.

Democrats in Congress have resolved to refuse President Trump’s demand to keep the government open past September 30, unless Republicans alter the Trump budget to restore deep cuts to Medicaid and the Affordable Care Act, and add guarantees that Trump won’t rely on impoundments to withhold congressionally appropriated funds, including for medical research services like the National Institutes of Health. There is increasing evidence that the proposed cuts in Medicaid and the ACA will raise premium costs for other consumers, since those programs indirectly subsidize the whole health care system.

The headlines suggest that Medicare will largely be untouched. But that turns out to be untrue. First of all, as my colleague David Dayen has reported, the budget deficits from the reconciliation bill trigger mandatory spending cuts that will hit Medicare to the tune of around half a trillion dollars over a decade. But Trump’s HHS is also rolling out a program that will use private vendors armed with AI tools to require preapproval of procedures before Medicare will pay for them. The program will initially be launched as a pilot in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington.

Until now, traditional Medicare has been an oasis of doctor-driven medicine in a desert of managed-care policies dictated by private insurers. Under traditional Medicare, you have free choice of doctor and hospital, and Medicare pays for all procedures that the doctor finds to be medically necessary. There are just a handful of exceptions that require preapproval, such as unproven spinal procedures.

. . .

This pilot program is a stalking horse for further privatization of Medicare. The so-called Medicare Advantage program, which is heavily managed commercial insurance financed by Medicare premiums, is already used by more than half the Americans eligible for Medicare. Project 2025 proposed making Medicare Advantage the default option for newly eligible seniors, and Dr. Oz has been a big booster of the idea.

A lot of the Trump program is complex and obscure, and its direct impact on consumers opaque. That helps Republicans in Congress to blindly rubber-stamp Trump and get away with it politically. Not so with increased health care costs and reduced choices.

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