The latest twist in Congressional efforts to enact a "doc fix" avoiding scheduled reductions in how much Medicare pays doctors is an interesting twist in the winding road of American ideology. The main pay-for the House Republicans are looking at to make this work seems to be rolling back some of the subsidies authorized in the Affordable Care Act to help non-elderly American afford health insurance.
Nominally, of course, we have a fierce ideological debate in the United States about "spending" and "free markets" and "entitlements." But the doc fix fights are telling in that not doing a doc fix would be a cut in entitlement spending that happens right away. By contrast, the House Republican budget plan adopted earlier this year would enact steep cuts in Medicare, but only for people born after 1955 and only starting in the year 2020. When it comes to currently elderly people in the present-day, the GOP is very much against a spending cut. But they're also against a tax increase, so they're insisting on an offsetting spending cut to prevent the Medicare cut. They want less government subsidization of health insurance for the non-elderly in order to provide a hgher level of government subsidization of health insurance for the elderly. That's a perfectly sensible thing to argue about. Given a semi-fixed capacity to deliver health care services in the United States (whether you want to see the limits as existing in the federal budget or existing on the "real" side of the delivery system) there are some meaningful tradeoffs between giving health care to 35 year-olds and giving it to 75 year-olds. And the two parties have very different demographic bases.