As a citizen of the United States, I sometimes feel as if I?m watching two speeding trains headed toward one another. Train No. 1 is loaded with the heavy weight of Medicaid and Medicare programs and the nearly 110 million people for whom they provide health benefits. Train No. 2 is filled with the mountains of U.S. debt, billions and billions of dollars of it, so much of it that it's about to explode out the train-car ceiling. How soon will these two trains crash?
Imagining that scenario is enough to send anyone to the nearest mental health facility?but, of course, they wouldn?t be able to get in following budget cuts and an overburdened system. Such is the state of the entire healthcare system?too much need and too few dollars to take care of the needs.

In the next few days, Congress and President Obama will begin fighting once again over whether to increase the $16.4 trillion debt limit, or whether to make significant budget cuts. Medicare, especially, will be in the crosshairs of budget cutters, and for good reason. We?re spending more than $550 billion a year to support Medicare and it's estimated to cost $1 trillion by 2021.

The last fiscal-cliff deal produced an agreement to raise taxes on the wealthiest Americans, but it lacked the complete overhaul some had wanted on ways to slow growth in so-called entitlement programs like Medicare and Medicaid. Likely to be seriously considered are increases in the Medicare eligibility age from 65 to 67; a move to greater cost sharing for Medicare beneficiaries with higher incomes; and more price competition among drug makers, insurers and providers.

The opposition will be swift and widespread. Already, advocacy groups of all stripes are crying foul because of the cuts they had to take in order to avoid deep cuts to reimbursement for physicians who see Medicare patients. Among them are speech and physical therapists and hospitals. In addition, the program funding loans for non-profit CO-OPs that were created in the Affordable Care Act was also axed, and advocates for that small slice of the ACA pie are crying foul and poised to fight to restore funding.

It's hard to imagine any of this ending well, especially given the high stakes supporting the ACA. While the ACA is designed to lower budget deficits over the long haul, the short haul is what's on many minds. And in the short haul, the ACA requires billions in new spending, for everything from Medicaid expansion to subsidies for low-income enrollees of state exchanges. There has lately been talk of the subsidies being axed from the ACA.

One has to wonder if the ACA might not have been passed at the worst possible time for success. True, we needed to do something about the high rate of uninsured?and the expensive way they access care?but to expect smooth sailing from a huge insurance expansion while the trains are about to collide may be just too much to ask.

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