TO CONTROL COSTS YOU INCREASE THE PORTION THE CONSUMER PAYS:

What would the $70 billion in offsets look like? Half would come from health care provider cuts (in particular a slower rate of growth for hospice and acute-care facility payments), but of course that would be more than offset by a permanent fix to overall payment rates. The changes would give more money to doctors and hospitals that improve the quality and coordination of care, which theoretically sounds excellent. 

It's the other half of the cuts that get problematic. There would reportedly be more means-testing for Medicare beneficiaries, increasing premiums for seniors showing income over $133,000 and couples over $266,000. These seniors would have to pay 65 percent of their total costs under the new plan. This would go up at higher incomes. Means-testing historically dips lower and lower as budgeters try to get more out of beneficiaries, so this continues that ratcheting process for Medicare. It's not necessarily where this line is set now but where it might go in the future that should cause concern.

Under the deal, new Medigap policies -- privately sold but publicly managed plans which fill in spaces in Medicare coverage -- would need a $250 deductible starting in 2020. Virtually every senior I've ever spoken with says that they need supplementary coverage because Medicare doesn't stretch far enough. But this would raise out-of-pocket expenses on all 9 million seniors with a Medigap plan, including the 86 percent of these beneficiaries who have incomes under $40,000, and almost half with incomes below $20,000. So this cut hits those who can't really afford it. (This idea, along with the means-testing, was in President Obama's budget, incidentally.) 

The proper term for this is cost-shifting, pushing funding for a public program onto those who get the benefits. 

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