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However the debt ceiling debate is resolved, it's expected to involve cuts to the massive Medicare health program. And that prospect has caused a huge backlash among Democrats and advocates for seniors. They say cuts would hurt those who can least afford to pay. But as NPR's Julie Rovner reports, history shows the program's beneficiaries are usually spared when Medicare gets a fiscal haircut.

JULIE ROVNER: It's not hard to see why Medicare stands out when the subject of deficit reduction is raised. It's expected to cost more than $560 billion this year - that's roughly 15 percent of federal spending for that one single program. And that's before 78 million baby boomers become beneficiaries, too.

So, the question isn't really whether Medicare spending needs to be restrained, but how. Democrats actually took a scalpel to Medicare as part of last year's health overhaul. They reduced future spending by more than $450 billion over 10 years. Almost all of those cuts were to health care providers, and will be felt little, if at all, by patients. But you wouldn't know it to hear the ads run by Republicans in last fall's elections.

(Soundbite of ad)

Unidentified Woman #1: Grayson and Kosmas, they betrayed the trust of Florida's seniors.

Unidentified Man #2: And this November...

Unidentified Group: We'll remember.

ROVNER: So, when Republicans in this year's budget bills actually did propose to increase costs to Medicare beneficiaries, Democrats were quick to fight back. Here's New York's Ed Towns on the House floor last week.

Representative ED TOWNS (Democrat, New York): Cutting back on Medicare is unfair to senior citizens who have worked hard all their lives and should not have to worry at this point whether they can afford to go to the doctor or buy the medicine that they need.

ROVNER: And many progressive and senior groups, including the influential AARP, want Medicare completely off the table during the deficit talks. Here's part of the ad AARP has been running.

(Soundbite of ad)

Unidentified Man #2: But instead of cutting waste...

Unidentified Man #3: ...or closing tax loopholes...

Unidentified Woman #2: ...next month...

Unidentified Woman #3: ...Congress could make a deal that cuts Medicare.

ROVNER: But how much are beneficiaries really at risk? Not that much, says Joe Antos. He's a health economist with the conservative American Enterprise Institute

Mr. JOE ANTOS (Health Economist, American Enterprise Institute): In fact, the political solution to all of Medicare's spending problems is to lower payment rates to hospitals, doctors, and everybody else. But the last thing they really want to do is directly go after benefits or eligibility.

ROVNER: Antos says Congress has actually been cutting Medicare almost as long as the program has been around and the targets have almost always been those who deliver health care rather than those who consume it.

Mr. ANTOS: We've had a series of cuts year after year after year. We've hardly ever directly touched beneficiaries.

ROVNER: Which is not to say that if you cut providers too deeply it won't affect patients. In 1997, for example, a bipartisan budget bill cut payments to private health plans so much that many of them dropped out of Medicare altogether. And currently scheduled cuts to physicians for next year are so large - about 29 percent - that Congress is expected to cancel them.

But Antos says that Congress can also make changes that can both save Medicare money and improve the quality of care. One example is the 1983 change in the way the program pays hospitals.

Mr. ANTOS: We saved an enormous amount of money by moving to that system. And in the process, we changed the way hospital service is delivered to people, and for the better, I think.

ROVNER: Eventually everyone, including patients, will probably have to pay at least a little more if Medicare is going to be able to withstand the onslaught of the baby boomers. But that's not something most elected officials are particularly eager to make happen, at least not if they want to be re-elected.

Julie Rovner, NPR News, Washington.

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