One of my many problems with the Senate health care reform bill that became law is that its terrible design left if open to a death by a thousand Republican cuts–and it appears the first few cuts are about to begin. From Politico:

Senate leaders are finalizing details on a one-year deal on the Medicare “doc-fix,” sources close to the negotiations say.

The tentative deal prevents a deep cut in Medicare doctors’ payments with changes in how much money consumers would have to repay if they receive too large a subsidy in the health insurance exchanges after 2014. [...]

Under the health care reform law, if a person gets more of a tax subsidy than they’re eligible for, they would have to repay no more than $250. Families would have to repay no more than $450. The deal on the table would raise those caps to between $600 and $3,500, depending on income.

[Note: Hitting people with a $2,000 fine from the IRS if you manage to increase your income modestly that year is not how you make a program popular.]

Less than a year after the bill passed, cutting the already completely insufficient exchange subsidies has turned into convenient pile of money members of Congress. I won’t be surprised if Congress goes back to this source of “savings” repeatedly. After all, only a relatively small number of relatively low income people will even qualify for exchange subsidies, making it very much like a welfare program.

Since these exchanges lack real cost control, the need to find savings in the exchange subsidy program is very likely going to just go straight to cuts in help to regular families. This fight over the SGR clearly shows that when the choice is reducing Hospitals and Doctor’s profits or cutting help to a limited number of middle class families, the middle class gets the ax.

This is the first set of cuts to weaken the heart of the entire structure of the law but, I don’t doubt for second they will be the last.