State of the Union Addresses Medicare Reform, Gun Control

February 12, 2013

In his fifth State of the Union address tonight, President Barack Obama spoke mostly as a Job Creator in Chief, Deficit Reducer in Chief, and Commander in Chief, but he took a few minutes to put healthcare policy on his second-term agenda, including the public health issue of gun violence.

"What I’ve said tonight," said Obama, "matters little if we don’t come together to protect our most precious resource — our children."

Shortly after the school massacre in Newtown, Connecticut, on December 14, Obama proposed a ban on military-style assault rifles and high-capacity magazines, universal background checks in gun sales, higher spending on mental health services, and other measures aimed at reducing gun violence. Tonight, Obama urged the gathered lawmakers to put these proposals to a vote in the name of victims of gun violence such as Hadiya Pendleton, a high-schooler who performed at Obama's second inauguration as a band majorette only to be shot 8 days later in her home city of Chicago, "just a mile away from my house."

"Hadiya’s parents, Nate and Cleo, are in this chamber tonight, along with more than two dozen Americans whose lives have been torn apart by gun violence," Obama said. "They deserve a vote."

In staking out these positions, the newly re-elected president antagonized the National Rifle Association (NRA) but made common cause with much of the medical community. Major medical societies such as the American Medical Association, the American Academy of Pediatrics, and the American Congress of Obstetricians and Gynecologists have voiced support for a bill sponsored by Sen. Dianne Feinstein (D-California) that would ban the sale of assault rifles.

President Barack Obama, flanked by Vice President Joe Biden and House Speaker John Boehner of Ohio, during the State of the Union address. AP Photo/Charles Dharapak, Pool

The lion's share of the domestic portion of Obama's speech focused on creating jobs. The president proposed doing that with federal investments in manufacturing, research and development, clean energy, infrastructure, and education, none of which, he promised, would "increase our deficit by a single dime."

"A growing economy that creates good, middle-class jobs — that must be the North Star that guides our efforts," said Obama. "Every day, we should ask ourselves 3 questions as a nation: How do we attract more jobs to our shores? How do we equip our people with the skills needed to do those jobs? And how do we make sure that hard work leads to a decent living?"

Medicare Pay Should Be Based on "Quality of Care"

In tonight's address to Congress, Obama reiterated his vision for Medicare in an era of deficit reduction. He said he is ready to pare budget-busting Medicare costs to the same extent as proposed by the bipartisan Simpson-Bowles fiscal commission in 2010. Obama's menu of reforms includes reducing taxpayer subsidies to prescription drug companies, increasing financial obligations for the wealthiest seniors, and shifting provider reimbursement to a pay-for-performance model.

"We’ll bring down costs by changing the way our government pays for Medicare, because our medical bills shouldn’t be based on the number of tests ordered or days spent in the hospital — they should be based on the quality of care that our seniors receive," the president said.

However, fiscal diets for giant entitlement programs such as Medicare and Social Security should not be so severe that they put the burden of deficit reduction mainly on seniors and the middle class "while asking nothing more from the wealthiest and most powerful," Obama said. Earlier this week, his administration announced that it opposed the idea of raising the eligibility age of Medicare from 65 to 67 years, a measure supported by Congressional Republicans.

Physicians Have Much at Stake in Sequestration

On Tuesday night, Obama once again asked Congress to devise a fair and balanced solution to roughly $1 trillion of automatic, across-the-board budget cuts — technically called sequestration — over 10 years that begin to take effect March 1 as a result of a deficit-reduction deal that Congress reached in 2011. Under that agreement, sequestration would kick in for both domestic and military spending if lawmakers failed — which they did — to enact legislation that would reduce the budget deficit by that amount in a more selective way.

Over the New Year's Day holiday, as part of its so-called fiscal-cliff legislation, Congress postponed sequestration from January 1 to March 1.

Obama wants to replace the first year's worth of automatic budget cuts — which total some $85 billion — with a mix of spending reductions and revenue-boosting tax reforms. In doing so, he would spare physicians an automatic 2% decrease in Medicare reimbursement as stipulated in the 2011 deficit-reduction agreement. And with sequestration temporarily held at bay, public health agencies such as the Centers for Disease Control and Prevention, the US Food and Drug Administration, and the National Institutes of Health would escape severe cuts.

The president and his Democratic allies in Congress would use the remainder of 2013 to pursue a more comprehensive deficit-reduction plan.

Tonight, Obama asked lawmakers to reach cross the proverbial aisle, which in Congress has become as cold and menacing as the old Berlin Wall, to devise a bipartisan solution.

"I realize that tax reform and entitlement reform won’t be easy," the president said. "The politics will be hard for both sides. None of us will get 100% of what we want. But the alternative will cost us jobs, hurt our economy, and visit hardship on millions of hardworking Americans. So let's set party interests aside, and work to pass a budget that replaces reckless cuts with smart savings and wise investments in our future."

Republican and Tea Party Critiques

In the official Republican response to Obama's speech, Sen. Marco Rubio (R-FL) repeated his party's familiar charge that the president's plans have backfired and will continue to backfire because they assume that big government can solve every problem, including the healthcare crisis.

The Affordable Care Act (ACA), Rubio claimed, is one exercise in backfiring. He said the ACA is causing some Americans to lose the health insurance coverage they are happy with, while the law's "expensive requirements" are causing some companies not only to freeze hiring, but also to force full-time employees into part-time status.

Obama's statements about Medicare tonight notwithstanding, the Florida senator asked when the president is going to offer a plan to save the program. "Tonight would have been a good time for him to do it," he said, adding that his party has already produced a detailed prescription for Medicare reform.

"I would never support any changes to Medicare that would hurt seniors," said Rubio. "But anyone who is in favor of leaving Medicare exactly the way it is right now, is in favor of bankrupting it."

The virtues of small government also were extolled by Sen. Rand Paul (R-KY) tonight in the official Tea Party take on Obama's State of the Union address.

"President Obama believes government is the solution: More government, more taxes, more debt," said Paul. "What the president fails to grasp is that the American system that rewards hard work is what made America so prosperous."

Paul said that Obama's policies will only add to the federal debt. He called for a balanced-budget amendment to the constitution with strict taxing and spending limits. Congress also must act to prevent Obama from using executive orders to legislate on matters like gun control.

"We cannot and will not allow any president to act as if he were a king," he said. "We will not let any president use executive orders to impinge on the Second Amendment."

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