Dr. Donald Berwick may not be a household name yet, but if he is confirmed as the head of the Centers for Medicare and Medicaid Services, the position for which he was nominated by President Obama, he may soon determine the direction of health care of millions of Americans.

So what’s the big deal about that? Earlier this week, a Washington Post editorial attributed the ongoing hold-up in Berwick’s confirmation hearing to “partisan politics,” claiming that “Republicans are seizing on the Berwick nomination as an opportunity to relitigate the health-care debate, latching on to a few of Dr. Berwick’s statements to wage their campaign.” The Post misses the point.

Don Berwick is not being scrutinized for political reasons, but rather due to his beliefs. Dr. Berwick has gone on the record—several times—as a passionate supporter of socialized medicine, including the cost-containment decisions that come with it. Whether to allow the government to ration or allow individuals to make their health choices isn’t even a question for Berwick—he claims that “The decision is not whether or not we will ration care—the decision is whether we will ration with our eyes open.”

It is not the sound bites which are important here—it is the vision for the U.S. health care system that Dr. Berwick has made crystal clear in his numerous writings and interviews. In a 2009 interview, Dr. Berwick outlined the three most important levels of knowledge to guide medical decision-making. First: whether a health intervention is effective at all. Second, whether it is more or less effective than comparable treatments. And third, whether the benefits of a more effective treatment outweigh additional cost. None of this is exceptional. There are limited resources, and ordinary Americans realize that there must be trade-offs and tough decisions. Individuals and families, in consultation with their physicians, are the ones who should be making those decisions, not government officials.

Beyond that, most ordinary Americans are not in favor of denying care to the sick because of the cost of providing it. This was abundantly evident with the public outcry against government rationing during committee consideration, including the defeat of anti-rationing amendments, of earlier versions of the Democrats’ health care overhaul. While the final bill signed by the president in March contains significant safeguards against this in its creation of the Patient-Centered Outcomes Research Institute, which will conduct comparative effectiveness research (CER), that does not settle the issue. .

The reason: the limitations are not sufficient to ensure the correct use of CER. CER alone would address the second tier of Berwick’s decision-making scheme: determining which among several treatments for an illness are most effective. This information would provide a useful tool for care providers to offer better care to their patients.

But the inclusion of cost information could open the door to denying coverage based on cost. Indeed, Sec. 6302 of the PPACA claims that the limitations put on the Patient-Centered Outcomes Research Institute “shall not be construed to…limit the application of differential copayments under [Medicare] based on factors such as cost or type of service…” And that brings us back to Dr. Don Berwick. With Dr. Berwick at the helm of the two largest public health programs, Medicare and Medicaid, the likelihood of CER being used to deny coverage based on cost becomes ever more worrisome. In his own words, the United States may one day find itself making health decisions based on the question of whether a health intervention “is so expensive that our taxpayers have better use for those funds.”

In June of 2009, President Obama told the American Medical Association that “identifying what works is not about dictating what kind of care should be provided.” Moreover, the president has assured the public time and again that the government will not get between patients and their doctors. His nomination of Don Berwick for Director of CMS, however, tells a different story.

The fight over Berwick is thus not just about partisan politics. Rather, it is the fight to create a health care system where a patient and doctor decide what is best for the patient, rather than a system where bureaucrats determine what treatment will give them the most bang for their buck.

This post was co-authored by Joshua Wade. Wade is a member of the Young Leaders Program at the Heritage Foundation. For more information on interning at Heritage, please visit: http://www.heritage.org/about/departments/ylp.cfm

Last week the Centers for Medicare and Medicaid Services (CMS) released the final cost projections for Obamacare, finding that, contrary to White House claims, the legislation will increase national health spending by $311 billion over the next decade and will cause 14 million Americans to lose their current employer-based health coverage. President Barack Obama unleashed his staff to attack Foster’s work. Nancy-Ann DeParle, director of the White House Office of Health Reform, and White House Communications Director Dan Pfeiffer downplayed and criticized Foster’s analysis on the White House website. As Heritage’s Rob Bluey reports this was not the first time the author of the report, Medicare and Medicaid chief actuary Rick Foster, had been attacked by a White House:

“Foster’s projections about the Medicare drug benefit in 2003 nearly cost him his job when the estimates didn’t conform to President George W. Bush’s prescribed talking points.”

“Foster later testified that he was ordered by a Bush administration official to deliberately withhold the information from Congress.”

Foster has since been asked to testify before at least four House committees. When they do, there are plenty of other alarms Foster’s report raises about Obamacare including:

– Millions Pay Fines Yet Remain Uncovered: 18 million Americans will pay $33 billion in penalties for failing to comply with Obamacare’s individual mandate.

– Firms Pay Billions to Comply with Employer Mandate: Between 2014-2019 firms that do not offer health insurance and are subject to the “play-or-play” mandate will pay $87 billion in penalties.

– Millions Placed on Welfare: Of the 34 million Americans who gain health insurance through Obamacare, over half (18 million) will receive it through the welfare program Medicaid.

– Millions Lose Medicare Advantage: 7.4 million seniors who currently get such services as coor­dinated care for chronic conditions, routine eye and hearing examinations, and preventive-care services would lose their existing private coverage.

– Seniors Lose Access to Care: Obamacare’s top down price control Medicare cuts will make 15% of all Medicare providers unprofitable thus “jeopardizing access to care for beneficiaries.”

Obamacare aims to insure the uninsured. To do that, the law bars insurers from denying coverage to people with pre-existing conditions—but not until 2014. In the meantime, the law calls for a national high-risk pool to offer coverage to the otherwise “uninsurable.”

Under the new law, an important deadline looms. By Friday, states must declare whether they will help implement the new risk-pools for their citizens, or if they’ll just let the U.S. Department of Health and Human Services do it for them.

Many states have taken one look at the financial outlook for these pools and run the other way—with good reason. Obamacare gives HHS $5 billion to administer the pools from now until 2014. However, the chief actuary of the Centers for Medicare and Medicaid Services reports:

“…the creation of a national high-risk insurance pool will result in roughly 375,000 people gaining coverage in 2010, increasing national health spending by $4 billion. By 2011 and 2012 the initial $5 billion in Federal funding for this program would be exhausted…”

So federal funding for the pools may run out two years early. That could leave states stuck with the entire bill a year or two down the line if they help create the pools today.

Politico reports that HHS promises that won’t happen. But states aren’t buying it. Georgia Insurance Commissioner John W. Oxendine says state legislators won’t implement a high-risk pool because it would “ultimately become the financial responsibility of Georgians in the form an unfunded mandate.” Officials in Kansas, Louisiana and elsewhere have similarly dug in their heels on the issue.

The risk pools are just one way in which the architects of Obamacare passed costs on to states to maintain a tenuous claim that the legislation was “deficit-neutral.” The expansion of Medicaid will cost states billions in the long run, since federal matching rates will decrease in future years.

Similarly, to increase access to care for Medicaid beneficiaries, Obamacare raises federal reimbursement rates for primary care physicians—but only for two years. After that, doctors will either receive the same low payments they do now, or the states will have to pick up the cost.

Of course, advocates of Obamacare can argue these really aren’t unfunded mandates on the states. After all, the states can refuse to pick up the tab when the feds leave the table. In that case, though, the financial shell game ends, and the whole Obamacare scheme falls apart.

But what about Al Gore’s Social Security “Lock Box?” Can’t we just spend that $2.5 trillion in the Social Security Trust Fund? As Heritage experts David John and Brian Reidl explain, since 1939 federal law has required Social Security to “invest” its extra money in Treasury bonds. Those bonds are really just IOUs from the government to the government. The feds already spent that $2.5 trillion long ago on programs such as education, foreign aid and defense. Add the $2.5 trillion Social Security obligation onto our other obligations and our current national debt stands at $12.5 trillion, or nearly $42,000 for every man, woman, and child in the country. And it will only get worse under President Barack Obama’s Budget. It would: 1) borrow 42 cents for each dollar spent in 2010; 2) leave permanent annual deficits that top $1 trillion as late as 2020; and 3) dump an additional $74,000 per household of debt into the laps of our children and grandchildren.

Responding to such unsustainable borrowing, Moody’s rating agency announced Monday that the United States needs to make deep spending cuts or risk losing its AAA credit rating. From the report: “growth alone will not resolve an increasingly complicated debt equation. Preserving debt affordability at levels consistent with AAA ratings will invariably require fiscal adjustments of a magnitude that, in some cases, will test social cohesion.”

Losing our AAA rating would send interest rates higher, increase our borrowing costs, and send the percentage of GDP we spend servicing our debt sky rocketing. Bloomberg adds: “the U.S. will spend more on debt service as a percentage of revenue this year than any other top-rated country except the U.K., and will be the biggest spender from 2011 to 2013.” The message from Moody’s was clear: the U.S. federal government must change direction on spending or face economic disaster.

The leftist majorities in Congress and the White House are not listening. Instead of reining in federal spending and tackling our existing Entitlement crisis, they are locked in an all out push to create a brand new $2.5 trillion health care entitlement. The President may say his plan is deficit neutral, but the American people do not believe him. And they are wise not to. The President tries to pay for his plan with over half a trillion dollars in Medicare cuts over the next decade. The president’s own Centers for Medicare and Medicaid Services reports that these cuts would cause one-fifth of all health care providers to go bankrupt. Congress would never allow those hospitals to go out of business. Congress will never actually make those Medicare cuts. So already Obamacare is half a trillion dollars in the red, and we haven’t even tacked on the hundreds of billion of dollars the doc fix adds on.

Reducing our entitlement obligations is the only way to prevent our nation from becoming another Greece. We need to: 1) to show these programs’ long-term obligations in the budget; target these programs to only who that need them; and strengthen personal responsibility by making it easier for people to build personal retirement savings and use health care savings accounts. But first we must avoid the fiscal insanity that is Obamacare.

At his impromptu press conference yesterday, President Barack Obama again defended his health care plan this time claiming:

“I don’t know if people noted, because during the health care debate everybody was saying the President is trying to take over — a government takeover of health care. I don’t know if anybody noticed that for the first time this year you saw more people getting health care from government than you did from the private sector — not because of anything we did, but because more and more people are losing their health care from their employers. It’s becoming unaffordable. That’s what we’re trying to prevent.”

First of all, we definitely noted the Centers for Medicare and Medicaid Services (CMS) report the President references above. But more importantly, if we are to take the President at his word, and believe him when he says he wants to prevent a government takeover of health care, then he should know that his plan is the exact wrong direction to go.

In a separate report on the Senate health bill issued earlier this year, the CMS projected that over half (18 million) of the 33 million Americans who would gain health insurance because of Obamacare, would do so by enrolling in Medicaid … which is a government run health care program. And another 2 million would enroll in Medicaid for supplemental coverage.

The President also said yesterday:

We’ve got to control costs, both for families and businesses, but also for our government. Everybody out there who talks about deficits has to acknowledge that the single biggest driver of our deficits is health care spending. We cannot deal with our deficits and debt long term unless we get a handle on that. So that has to be part of a package.

But guess what? According to that same CMS report, Obamacare would increase, not decrease, U.S. health expenditures by $234 billion by 2019.

President Obama said of his February 25th health care infomercial:

Let’s establish some common facts. Let’s establish what the issues are, what the problems are, and let’s test out in front of the American people what ideas work and what ideas don’t. And if we can establish that factual accuracy about how different approaches would work, then I think we can make some progress.

As the facts above clearly show, if reducing health care spending and stopping the government takeover of health care are your priorities, then Obamacare needs to be scrapped and Congress needs to start over.

For the past several months, Washington has exhausted every possible method to pass a health care bill designed to increase government’s control over health care. They haven’t been successful yet, but that may not matter: even without Obamacare, government health spending is set to increase far faster than private health expenditures, surpassing the private sector as soon as 2012.

Today the Centers for Medicare and Medicaid Services released its projections of national health expenditures for the next ten years. The report shows that spending by the public sector grew much faster in 2009 at 8.7 percent, compared to the private sector which only grew at 3.0 percent. Though public spending was heightened by the recession, as unemployment caused more Americans to lose employer-sponsored coverage and enroll in Medicaid, the trend is expected to continue into the next decade.

What is more, the report bases its projections on current law. In the case of Medicare, this underestimates future spending. Under current law, Medicare is set to reduce physician reimbursement rates by 21.3 percent in 2010. This would lead to growth in Medicare spending of just 1.5 percent in 2010. However, the likelihood of these cuts coming to fruition is slim to none, as every year, Congress votes to suspend them. 2010 will likely be no different. A report by Health Affairs cites that, if physician payment rates are held constant, the more likely growth in Medicare will be 5.1 percent in 2010. Whether or not these physician cuts occur is no small matter—with them, overall health spending growth would be 3.9 percent. Under the more likely scenario, health spending growth would be 4.7 percent.

Thus far, the debate on health care reform has focused on increasing government spending to reduce the number of uninsured. But government spending should be moving in the opposite direction. With government spending growing at a fast clip, rather than overhaul the entire system, lawmakers should channel reform towards high-cost (and largely cost-inefficient) government programs, like Medicare and Medicaid.

Medicare, Medicaid, and Social Security, the three entitlements big spenders, are duly in need of attention from Congress. These programs will be responsible for unsustainable growth in government spending in the years to come, and will quickly become insolvent. By reforming entitlement programs, Congress could kill two birds with one stone: achieve long sought-after health care reform and bend the cost curve in health care spending, all the while addressing the fiscal crisis facing the nation due to out-of-control spending.

Rather than increase government’s role in the health care system, Congress should see the current trend for what it is: a cry for reform of existing government health care programs. Getting public health spending under control would have a monumental effect on overall spending, directly and indirectly reducing costs for all Americans.

The Chief Actuary for the President’s own Centers for Medicare and Medicaid Services issued an extensive analysis of the pending Reid bill and House-passed bill. The Lewin Group also released an analysis of the House and Senate bills. These reports provide a comprehensive overview and impact of the legislation. Here are a few important facts from the reports:

More Health Care Spending, Not Less
A key argument by the President and Congress for health care has been to bring health care spending down. However, both studies expose that instead of bring health care spending down, the House and Senate bills would increase health care spending.

– The Actuaries report estimates that health care spending would increase under the Senate bill by $234 billion between 2010 and 2019 and $750 billion between 2010 and 2019 under the House bill.

– The Lewin Group estimates the Senate bill would increase health care spending by $305 billion between 2010 and 2019 and $781 billion in the second decade. Under the House bill, Lewin Group estimates health care spending would increase by $425 billion between 2010 and 2019 and $955 billion in the second decade.

Adds to the Deficit, Not Reduces
In his address to Congress, the President promised the American people the bill would not add one dime to the deficit. While that may be technically correct, it is does not show the whole picture. The House and Senate bills excluded – not by accident – the costly provisions to the Medicare physician payment formula. The Lewin Group considered the impact of incorporating the costly physician payments changes into the larger health care bill to show the full impact on the deficit.

– The Lewin Group estimates that when including the impact of correcting the Medicare physician payments, the federal deficit would increase by $196 between 2010 and 2019 and $765 billion in the second decade under the Senate bill. Under the House-passed bill, the federal deficit would increase by $77 billion between 2010 and 2019 and $591 billion in the second decade.

Costs and Premiums Go Up for Many
Although not highlighted as often anymore, the President promised that health insurance premiums would go down as a result of these bills. The analysis by Lewin Group actually shows there are big losers under the Senate and House bills.

– Once fully implemented, health care spending per worker will increase for all employers who do not currently offer coverage — $316 per worker under the Senate bill and $800 increase per worker under the House bill. Depending on the firm size, it can get even worse. For example, under the Senate bill, employers with fewer than 10 workers would see a cost increase of $374 per worker. Under the House bill, employers with more than 100 workers would see an increase of $1,182 per worker.

– Once fully implemented, average annual health care spending per family would also increase — $66 per family under the Senate bill and $83 per family under the House bill. While spending may go down for lower income families, families earning over $50,000 would see an increase of over $200 in annual health care spending under both the Senate and House bills, increasing further by income.

– Currently uninsured families (with one or more uninsured members) would face significant increase in health care spending. The Lewin Group estimates uninsured families would pay $1,225 more per family/per year under the Senate bill and $1,308 more per family/per year under the House bill.

Loss of Employer Based Coverage
As a result of the structure of the House and Senate bills, many employers would find it advantageous to drop their existing coverage. Therefore, workers who currently have employer-based coverage would be transitioned out of their existing coverage.

– The Actuary’s report estimates that the number of people currently with employer based coverage would drop by 17 million under the Senate bill and 12 million under the House-passed bill.

– The Lewin Group estimates 16 million employers would drop coverage under the Senate bill and 18 million employers would drop coverage under the House bill.

No Choice for the Poor
One major theme of the health care debate has been to increase choice and competition in the health care system. Unfortunately, according the Actuary’s report and the Lewin Group, millions of uninsured Americans will not have choice, but forced to join a poor quality, government-run health care plan – Medicaid.

– The Actuary’s report estimates about half (18 million) of the newly insured will end up on Medicaid as a result of the Senate bill and House bills.

– The Lewin Group estimates 14 million more people would end up on Medicaid under the Senate bill and 12 million more under the House bill.

Millions Remain Uninsured
Besides claims to bend health care spending down, advocates for these proposals claim expanding coverage as a major goal for the trillion dollars legislative proposals. However, according to the Actuaries report and the Lewin analysis, millions of people would still remain uninsured under the House and Senate bills.

– The Actuary report estimates 19 million Americans would remain uninsured under the Senate bill and 18 million Americans would remain uninsured under the House bill.

– The Lewin Group analysis estimates 18 million Americans would remain uninsured under the Senate bill and 16 million would remain uninsured under the House bill.

According to that report, Obamacare: 1) raises health care costs; 2) causes millions of Americans to lose their current health care coverage; 3) forces millions of Americans to pay fines and still receive no health insurance; 4) causes millions of seniors to lose their Medicare Advantage plans; 4) places millions of Americans on welfare; 5) jeopardizes Medicare access for all seniors; 6) worsens health care access for the poor.

This past Friday, CMMS issued another report, this time on Majority Leader Harry Reid’s (D-NV) version of Obamacare and the verdict was in many ways worse: 1) health care costs would rise by $234 billion; 2) 17 million Americans would be forced out of their existing health insurance; 3) 19 million Americans would pay $29 billion in taxes/fines and receive no health care in return; 4) 33% of all Medicare Advantage customers would lose their health care plan; 5) 18 million Americans would be put on welfare; 6) the $493 billion in Medicare cuts would force 20% of Medicare providers to become unprofitable thus jeopardizing access to care for all seniors; and 7) the explosion in Medicaid recipients would exacerbate existing health care access problems for the poor.

The week before the Senate began debating Obamacare, CNN conducted a poll and found that Americans narrowly opposed the plan, 49% to 46%. Now that the Senate has been debating the plan for two weeks, and CMMS has issued two devastating reports on what the impacts of Obamacare would be, opposition to the plan has skyrocketed. This Friday’s latest CNN poll showed 61% of Americans now oppose Obamacare compared to just 36% who support it.

Liberals are is beginning to see the writing on the wall. They know that if Obamacare fails to pass the Senate this year, the battle will be on to explain its failure. For them, the story can not be that President Barack Obama tried to push too ambitious a government health plan. It must be that the President and Congress did not go far enough to the left to satisfy the supposedly government-hungry American people. Hence the left is now attacking the White House and Reid over the public option, the employer mandate, drug reimportation, abortion, and health insurance spending caps.

Obamacare is not dead yet. Speaker Pelosi has signaled that she will quickly pass anything that comes out of the Senate, so Reid could still cave on almost everything and get a terrible bill from everybody’s prospective on the President’s desk by New Years. But Senators thinking about moving quickly should remember that the public strongly opposes this bill, and that opposition is only rising.

Health Care Costs Increase: “In aggregate, we estimate that for calendar years 2010 through 2019 [national health expenditures (NHE)] would increase by $289 billion, or 0.8 percent, over the updates baseline projection that was released on June 29, 2009.” In other words, Obamacare bends the cost curve up, not down.

Millions Lose Existing Private Coverage: “However, a number of workers who currently have employer coverage would likely become enrolled in the expanded Medicaid program or receive subsidized coverage through the Exchange. For example, some smaller employers would be inclined to terminate their existing coverage, and companies with low average salaries might find it to their – and their employees’ – advantage to end their plans … We estimate that such actions would collectively reduce the number of people with employer-sponsored health coverage by about 12 million.” In other words, Obamacare will cause millions of Americans to lose their existing private coverage.

Millions Pay Fines Yet Remain Uncovered: “18 million are estimated to choose not to be insured and to pay the penalty associated with the individual mandate. For the most part, these would be individuals with relatively low health care expenses for whom the individual or family insurance premium would be significantly in excess of the penalty and their anticipated health benefit value.” In other words, 18 million Americans will be forced to pay a new tax they will receive no benefit from or face jail time.

Millions Lose Medicare Advantage: “Section 1161 of Division B of H.R. 3962 would set Medicare Advantage capitation benchmarks … We estimate that in 2014 when the MA provisions would be fully phased in, enrollment in MA plans would decreased by 64 percent (from its projected level of 13.2 million under current law to 4.7 million under the proposal).” In other words, 8.5 million seniors who currently get such services as coor­dinated care for chronic conditions, routine eye and hearing examinations, and preventive-care services would lose their existing private coverage.

Millions Placed on Welfare: “Of the additional 34 million who are estimated to be insured in 2019 as a result of H.R. 3962, about three-fifths (21 million) would receive Medicaid coverage due to the expansion of eligibility to those adults under 150 percent of the FPL.” In other words, more than half the people who gain health insurance will receive it through the welfare program Medicaid.

Seniors Access to Care Jeopardized: “H.R. 3962 would introduce permanent annual productivity adjustments to price updates for institutional providers… Over time, a sustained reduction in payment updates, based on productivity expectations that are difficult to attain, would cause Medicare payment rates to grow more slowly than and in a way that was unrelated to, the providers’ costs of furnishing services to beneficiaries. Thus, providers for whom Medicare constitutes a substantive portion of their business could find it difficult to remain profitable and might end their participation in the program (possibly jeopardizing access to care for beneficiaries).” In other words, the Medicare cuts in the House bill are so out of touch with reality that hospitals currently serving Medicare patients might be forced to stop doing so. Thus making it much more difficult for seniors to get health care.

Poor’s Access Problems Exacerbated: “In practice, supply constraints might interfere with providing the services by the additional 34 million insured persons. …providers might tend to accept more patients who have private insurance (with relatively attractive payment rates) and fewer Medicaid patients, exacerbating existing access problems for the latter group.” In other words, those 21 million people who are gaining health insurance through Medicaid are going to have a very tough time finding a doctor who will treat them.

Reacting in part to Friday’s CMS report, Robert J. Samuelson writes in today’s Washington Post:

The disconnect between what President Obama says and what he’s doing is so glaring that most people could not abide it. The president, his advisers and allies have no trouble. But reconciling blatantly contradictory objectives requires them to engage in willful self-deception, public dishonesty, or both.

There is a reason why as more Americans learn about Obamacare, the less popular it gets.

Quick Hits:

• Commenting on President Barack Obama’s meeting with Emperor Akihito of Japan, an academic with expertise about the Japanese Empire tells ABC News: “The bow as he performed did not just display weakness in Red State terms, but evoked weakness in Japanese terms….The last thing the Japanese want or need is a weak looking American president and, again, in all ways, he unintentionally played that part.”
• Thanks to conservatives in Congress, President Obama has been “hobbled” in his search for a global warming treaty.
• The government paid more than $47 billion in questionable Medicare claims including medical treatment showing little relation to a patient’s condition, wasting taxpayer money at a rate nearly three times that of the previous year.
• Former Assistant Secretary of Treasury and Deputy Assistant to President George W. Bush Tony Fratto explains why President Obama’s trip, and his “new engagement” with Asia, ignores the achievements of many past U.S. presidents.
• After $111 billion in bailouts for Fannie Mae and Freddie Mac, the Federal Housing Administration is also close to a taxpayer bailout.

Under Section 1209, if the President certifies that the changes under this legislation cause an increase in the federal deficit, “… the President shall instruct the Secretary of Health and Human Services and the Secretary of the Treasury to reduce such credits and subsidies …” that are provided under the legislation.

In other words, the level of federal assistance that is being promised may not actually be delivered. Reducing the subsidies would fall disproportionately on the lowest income levels. Having trapped millions of Americans into buying a product they cannot afford, Congress now gives the President the full unchecked authority to reduce those subsidies (which are worth up to $16,500 a year for a family of four).

This provision abdicates Congress’ responsibility to provide alternative means of lowering costs. This is just another massive relinquishment of power by Congress to the Obama Czar State. Consider if such power were given to the President in other government assistance programs? Imagine the protests from senior groups if such power were in the hands of the Commissioner of the Social Security Administration and the Administrator of the Centers for Medicare and Medicaid Services ? The unfunded liabilities of Social Security and Medicare would be resolved, of course, but it would come directly out of the hides of beneficiaries.

No doubt the Administration and congressional leaders will try to convince themselves and everyone else, this provision does not really mean what it says it means, it is there only to fool those good but pesky analysts at the Congressional Budget Office. But at what point will the Obama Administration and congressional negotiators ask themselves, are we so desperate on this one issue, we are willing to put everything else at risk?