Now that Rep. John Boehner (R-Ohio) and his GOP coalition have put a fiscal framework on the table that includes Medicare, the loosely knit alliance of pro-Medicare and progressive groups have started digging in for a vigorous defense of the program.

"Pro-Medicare progressives" range from Democrat lawmakers speaking out mainly along party lines to advocacy groups who embrace a slower shift within the current structure of the program rather than a radical restructuring akin to moving to a defined benefit, or premium support, model.

On Dec. 3, Boehner announced that part of his $2.2 billion "Grand Bargain" fiscal cliff plan would likely include raising the Medicare eligibility age for everyone and premiums for wealthy beneficiaries. While there were few details beyond that, it was enough to trigger a response and behind-the-scenes organizing by a number of groups opposed to those measures.

Boehner laid out the skeleton of his Medicare reform plan in a letter emailed to President Obama on Dec. 3, which indirectly references a previously passed House resolution on the GOP-backed budget earlier this year, which never made it to the Senate. Although it's not entirely clear, it appears to refer to Ryan’s proposal to partially privatize Medicare and to offer annual vouchers for health expenses. This would not change the system for those now 55 or older, who would still be able to participate in the fee-for-service system.

"We achieve these reforms without affecting current seniors or those nearing retirement,” he wrote. “This would slow the projected explosive spending growth in this program and eventually maintain Medicare spending as a share of the economy at 4.75 percent, thus saving the program for future generations."

As a counter-offer to Obama's proposal last week, which reiterated earlier proposals for modest changes to Medicare—including increasing out-of-pocket costs for wealthier Americans—the Boehner plan did not indicate any change in positions from earlier GOP reform proposals.

The White House, which summarily rejected the Boehner plan because it didn't raise income-tax rates for upper-income Americans, criticized the GOP letter for its vagueness and failure to offer a "balanced" approach that combined tax increases with spending cuts. Dan Pfeiffer, the White House communications director, blasted the GOP for offering "no details on which deductions they would eliminate, which loopholes they will close or which Medicare savings they would achieve."

The Progressive Response

While pro-Medicare groups have been mostly silent during the fiscal cliff debate, they have been loudly vocalizing their opposition to GOP plans. Via a Dec. 3 blog posting by Ruy Teixeira, the Center for American Progress (CAP), a leading progressive think tank tied to the Obama administration and the Democratic Party, immediately attacked one piece of Boehner's proposal that calls for raising the Medicare eligibility age:

"Raising the Medicare eligibility age is a no-no. In the same poll (Washington Post/ABC News), the public rejected the idea of raising the Medicare eligibility age from 65 to 67 by an overwhelming 67 percent to 30 percent margin."

Some key activists in the progressive camp also began to adopt a hard line against the GOP's proposal. Rep. Keith Ellison (D-MN.), co-chair of the House progressive caucus, issued a statement on Nov. 29 in anticipation of the Boehner proposal:

"Progressives will not support any deal that cuts benefits for families and seniors who rely on Medicare, Medicaid and Social Security to put food on the table or cover their health costs…. We should allow Medicare Part D (Prescription Drug Plan) to negotiate lower drug prices for seniors and by requiring the wealthy to contribute to Social Security on all of their wages, as middle class Americans do now. But cuts like raising the retirement age would cost seniors thousands of dollars, and increase the cost of health care by over $11 billion."

With several former cabinet members such as Robert Rubin and Lawrence Summer as authors, CAP has issued several joint statements in recent weeks defending the Obama adminstration's policy to internally reform Medicare. It has issued a "senior protection plan" that calls for "structural reforms" such as accountable care, bundled payments, increased premiums for wealthier recipients, market-based pricing for products/services and obtaining Medicaid-style rebates for drug purchases. Contained in CAP's  "Reforming Our Tax System" report issued earlier this week, it echoes many programs proposed earlier or under way through the Affordable Care Act (ACA).

An even harder line was heard from MoveOn.org, the progressive group that extensively employs social media for Democrat-aligned and progressive causes. In a video on MoveOn's website, former Labor Secretary Robert Reich stated one of the talking points for progressives "in understanding the fiscal cliff" was a refusal to "sacrifice Medicare, Social Security and Medicaid," which the GOP typically lumps together under the heading of "entitlement reforms."

The MoveOn stance may put it at odds with the White House, which seeks some compromises on Medicare to resolve the impasse on the competing fiscal proposals. Ilya Sheyman, MoveOn's campaign director and former candidate for Congress, told Salon:

"So let me be crystal clear. Any benefit cuts in Medicare, Medicaid, or Social Security, including raising the retirement or eligibility age, are absolutely unacceptable. More than 80 percent of MoveOn’s seven million members say they want us to fight a deal that cuts those benefits, even if it also ends all of the Bush tax cuts for the top 2 percent."

Most of the rhetoric coming from progressives is hardly new, but it raises an interesting wrinkle in the fiscal-cliff dilemma.

If it appears that the White House is accepting significant Medicare cutbacks—beyond the structural changes enacted by the ACA and the FY 2013 budget—how will progressives oppose allies in the White House? They may counter by campaigning for concepts that the White House has already put forth in the 2013 budget or join some of the more established groups for seniors such as the AARP or Committee to Preserve Social Security and Medicare.

Under the theme of "program integrity," the White House has offered a number of incremental savings that amount to around $400 billion. These include allowing Medicare to negotiate broad discounts for its Part D drug program using Medicaid-style rebates, cutting subsidies for post-acute care and raising premiums for wealthier beneficiaries and Medicare supplement buyers.

It remains to be seen whether the White House will go beyond the above-stated "savings" and venture into the realm of even more radical reform at this point in the fiscal-cliff battle. The next tier of savings may involve chipping away at the Medicare’s expensive, but popular, "fee-for-service" model, which many progressives have suggested needs to be reexamined and possibly abandoned over time. 

Despite the pitched battle that has created this political equivalent of a World War I-style stalemate, radical reform—if it comes at all—will most likely be delayed or shunted to another blue-ribbon panel later in 2013 or perhaps in 2014. It's far too complicated and politically toxic to undertake now as Congress faces a year-end deadline with no compromise in sight.  

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