Sarah Kliff writes that “If the Supercommittee does not come up with enough savings, and the trigger cuts go into effect, the Affordable Care Act comes out in relatively decent shape.” She argues that “Medicaid, which will expand up to 133 percent of the Federal Poverty Line in 2014, is shielded from the trigger,” as are the premium subsidies. The provisions that are vulnerable to attack — the cost sharing assistance, exchange grants — would see “a trim and not a wipeout.” “A small cut on the federal level could, for example, throw a wrench in the plans for states looking set up exchanges, particularly in cash-strapped states. So while the cuts aren’t expected to be huge, they could still have an impact,” Kliff concludes.

I think this really understates that impact. Consider this full list of all the potential provisions that could be at risk (Sen. Barrasso’s office informs me that this is the same list they’re working off):

– Cost-sharing Subsidies (Section 1402): Approximately $111 billion from 2014-2021.
– Risk Adjustment (Section 1342): More than $100 billion from 2014-2021.
– Prevention and Public Health Fund (Section 4002): A total of $16.75 billion from 2013-2021.
– Rate Review Grants (Section 1003): Funds from the initial $250 million that remain available in 2014.
– High-Risk Pool Funding (Section 1101): Funds from the initial $5 billion that remain in 2013 and 2014.
– Health Insurance Cooperatives (Section 1322): $3.8 billion.
– Re-insurance for Early Retirees (Section 1102): $5 billion, but likely that the funds will be obligated before 2013.
– Health Insurance Exchange Administrative Grants (Section 1311): Unspecified amounts in FY2013 and FY 2014.
– Community Health Centers Fund (Section 10503(b)(1)): A total of $7.3 billion for FY2013 through 2015.
– Health Center Construction and Renovation (Section 10503 (c)): Funds remaining from the initial $1.5 billion remain available until FY 2015.
– National Health Service Corps (Section 10503 (b)(2)): A total of $900 million in mandatory funding for 2013, 2014, and 2015.
– Maternal, Infant, and Early Childhood Home Visiting Program (Section 2951): A total of $800 million in mandatory spending in 2013 and 2014.
– Personal Responsibility Education Programs (Section 2953): A total of $150 million for 2013 and 2014.
– School Based Health Centers (Section 4101): $50 million in FY 2013.
– Patient Centered Outcomes Research Trust Fund: A total of $1.05 billion between 2013 and 2019.

Certainly this isn’t the very heart of reform — not in the same way that the mandate is, anyway. But all of these pieces work together to improve the effectiveness of the law. So if the federal government is paying insurers less for the extra costs associated with lower patient cost-sharing, then insurers will increase premiums (causing the government to spend more on premium support), or try to avoid lower-income beneficiaries altogether.

Similarly, the money for the National Health Service Corps and the community health centers is necessary to provide the capacity to care for the newly insured. The risk adjustment is critical for ensuring the viability of the market reforms and the exchanges. And on down the list. Before long, you’re compromising on the very goals of reform — expanding access and lowering costs — and as you peel back provision after provision, you’re left with a much smaller, less ambitious, less progressive plan, that isn’t worth the nine or more months you spent working on it! Or, worse yet, pull on too many strings all at once and the whole thing unravels.

But what’s still even more alarming is that if these cuts become reality, they’ll establish a strong precedent for policy makers to use the law as a “pay for” on future legislation. If you’re going to reduce the cost sharing subsidies, why not go after the premiums? And so the trigger is a very painful fallback. Given where we are, lawmakers should fight for the best deal possible in the super committee — assuming the GOP agrees to revenue increases. And, if more health care advocates are elected in 2012, they may have the votes necessary to make changes that would cushion the blow to the law.

Wisconsin Governor Scott Walker (R) has rejected more than $9 million in grants from the Affordable Care Act that would have “focused on fighting drug and alcohol abuse; assessing health impacts of public policies; and signing up state residents who qualify for state health programs.” State health commissioners are outraged by the move, pointing out that the state is turning away money “at a time when there is a proliferation of illicit drugs and documentation of binge drinking and drunken driving in the state.” “Wisconsin would put its head in the virtual sand and not go after this funding,” Bevan Baker, commissioner of health for the City of Milwaukee said.

Walker’s administration claims the grants “duplicated existing efforts,” despite making significant cuts to health care programs in the state’s recently-passed state budget. Walker slashed $500 million from Department of Health Services and instituted a $1.6 billion reduction in public school funding.

In fact, some of the budget cuts specifically targeted drug and alcohol prevention programs in schools, while others will allow the health department’s secretary, Dennis Smith, “sole authority to make cuts to whatever programs he likes — or doesn’t like.” Smith hasn’t yet offered a finished proposal, but wouldn’t rule out cuts to addiction services.

Wisconsin is also near the very bottom of states for public health funding, ranking 49th in the nation for state funding of prevention services per capita.

Piling on to the conservative apoplexia over the Obama administration’s recent ruling that insurance companies should cover birth control without co-pays, Fox News host Sean Hannity slammed the policy last night for encouraging “screwing around,” but defended coverage of Viagra. Taking a bold stance again reason, Hannity said, “I don’t care about the scientists” who recommended the move and insisted that the birth control is “not a women’s health issue.” Asked how he felt about insurance companies covering male enhancement medication, Hannity strongly defended the practice, saying, “That is a medical problem!” Watch excerpts from the segment:

Hannity may be surprised to know that the overwhelming majority of policies — particularly employer policies and the federal government’s health care — already cover birth control. Meanwhile, at least 27 states already require insurers to cover birth control. More than 99 percent of all women ages 15 to 44 who have ever had sexual intercourse have used at least one contraceptive method. Overall, 62 percent of the 62 million women ages 15 to 44 are currently using a method of contraception.

The trigger in the debt ceiling deal could also affect “a popular nutrition program for low-income women and young children,” Congressional Quarterly’s Ellyn Ferguson is reporting. Lawmakers had initially considered shielding the program known as Special Supplemental Nutrition Program for Women, Infants and Children or (WIC) — which provides assistance to “an estimated 9 million pregnant women, breast-feeding mothers and children under age 5″ — but that provision was not included in the final deal, meaning that it could be vulnerable to sequestration if the 12-memeber Congressional super committee does not agree on a spending plan:

The caps still leave wiggle room to protect some programs while reducing funding for others, said Jim Horney of the Center on Budget and Policy Priorities. “It’s not singled out,” said Horney, the center’s federal fiscal policy vice president. “Appropriators could choose to do full funding of WIC although everything will be under pressure.”

WIC, which is funded at $6.7 billion for fiscal 2011, could be more directly affected by debt ceiling provisions that call for sequestration of appropriated program funds in fiscal 2013. Horney said the debt-ceiling negotiations included discussion of an exemption for WIC similar to one it had under a 1990 budget act (PL 101-508), but it was not included in the final version.

As Pat Garofalo has reported, WIC has been the target of various cost cutting schemes, from a bipartisan agreement to avoid government shutdown in April to the 2012 Agriculture Appropriations bill. The measure cuts WIC by $733 million and, if signed into law, it would effectively kick between 300,000 and 450,000 women and young children out of the program.

Economists estimate that every $1 invested in WIC saves between $1.77 and $3.13 in health care costs in the first 60 days after an infant’s birth by reducing the instance of low-birth-weight babies and improving child immunization rates. In fact, it is estimated that the program has saved more than 200,000 babies from dying at birth.