By Rebecca Adams, CQ HealthBeat Associate Editor

The idea of charging higher-income beneficiaries more for Medicare services was once so controversial that those willing to discuss it were quickly dismissed as unelectable. Just ask Bruce Babbitt.

The former Clinton administration Interior secretary and Arizona governor was a proponent of means testing, and that was one reason his bid for the 1988 Democratic presidential nomination failed. Democrats, then and now, said broad support for Medicare would unravel, collapsing the social compact, if wealthier seniors had to pay more or saw their benefits trimmed.

Now, momentum is again building to link Medicare premiums to income. House Speaker John A. Boehner, R-Ohio, endorsed the idea last week, and House Minority Whip Steny H. Hoyer, D-Md., said he would consider it.

Though some consider it apostasy, Congress has twice required higher-income seniors to pay more for benefits, first in 2003 and again in 2010. The fundamental shift in Medicare attracted such little public notice that even former top Medicare officials initially were unaware of the most recent means-testing provisions included in last year’s health overhaul.

Congress is unlikely to fundamentally restructure Medicare this year. But more means testing, technically known as income-relating, could be part of a deficit reduction package expected to accompany an increase in the debt limit. Medicare’s annual fiscal outlook, released May 13, projected that the inpatient care trust fund will go broke in 2024, and that only underscores the likelihood lawmakers will turn to means testing to lessen fiscal problems.

The health care overhaul also took steps to trim the growth in Medicare spending to pay for expanding health coverage for the under-65 population. That, too, gives lawmakers more incentive to require wealthier beneficiaries to pay more for Medicare benefits.

Only a small percentage of seniors has been required to pay more for benefits since Congress instituted means testing. In 2010, about 5 percent of Medicare beneficiaries paid a higher, income-related premium, according to the Kaiser Family Foundation. Still, the move represents a major philosophical shift from Medicare’s founding principle in 1965 (PL 89-97) that all seniors would get equal benefits regardless of income.

One reason so little political uproar followed Congress’ inclusion of means testing for some benefits is that each time Congress embedded the changes in large, politically charged health care measures.

In 2003, for example, Sen. Dianne Feinstein, D-Calif., tucked a provision into a measure to provide Medicare recipients with prescription drug coverage (PL 108-173) requiring those with annual incomes above $85,000 to pay higher premiums for Part B outpatient services. The income threshold was tied to inflation to stop it from hitting many more seniors each year.

The health care overhaul (PL 111-148, PL 111-152) went further and tossed aside the inflation adjustment, meaning more seniors would pay more over time. It also reduced the prescription drug subsidy for those earning more than $85,000, and Congress increased Medicare payroll taxes on the wealthy.

The Tipping Point

It’s difficult to predict what additional hike in Medicare charges will spark public opposition. Robert Reischauer, a former Congressional Budget Office director, said if lawmakers want to cut Medicare costs significantly, they will have to target a broader group and charge them more than they do now. There just are not enough rich seniors to raise what is needed, he said. The median income of Medicare beneficiaries was $20,644 in 2010, according to the Kaiser foundation.

In April, House Budget Chairman Paul D. Ryan, R-Wis., revived the means-testing debate with his fiscal 2012 budget blueprint that called for shifting more costs to higher-income beneficiaries. Boehner, too, pitched the idea in a May 9 speech to the Economic Club of New York attended by billionaire Peter G. Peterson. “For people of means, there’s no reason why we should subsidize Pete Peterson’s premium,” Boehner said. “I’m sorry. He ought to pay the full cost of his premium to be in Medicare.”