The Associated Press reports that millions of older people and the disabled face shrinking Social Security checks next year, the first time in a generation that payments would not rise.

The trustees who oversee Social Security are projecting there won’t be a cost of living adjustment (COLA) for the next two years. That hasn’t happened since automatic increases were adopted in 1975.By law, Social Security benefits cannot go down.

Nevertheless, monthly payments would drop for millions of people in the Medicare prescription drug program because the premiums, which often are deducted from Social Security payments, are scheduled to go up slightly.

“I will promise you, they count on that COLA,” said Barbara Kennelly, a former Democratic congresswoman from Connecticut who now heads the National Committee to Preserve Social Security and Medicare. “To some people, it might not be a big deal. But to seniors, especially with their health care costs, it is a big deal.”

Cost of living adjustments are pegged to inflation, which has been negative this year, largely because energy prices are below 2008 levels.

Advocates say older people and the disabled still face higher prices because they spend a disproportionate amount of their income on health care, where costs rise faster than inflation. Many also have suffered from declining home values and shrinking stock portfolios just as they are relying on those assets for income.

“For many elderly, they don’t feel that inflation is low because their expenses are still going up,” said David Certner, legislative policy director for AARP. “Anyone who has savings and investments has seen some serious losses.”

About 50 million retired and disabled Americans receive Social Security benefits. The average monthly benefit for retirees is $1,153 this year. All beneficiaries received a 5.8 percent increase in January, the largest since 1982.

More than 32 million people are in the Medicare prescription drug program. Average monthly premiums are set to go from $28 this year to $30 next year, though they vary by plan. About 6 million people in the program have premiums deducted from their monthly Social Security payments, according to the Social Security Administration.

Millions of people with Medicare Part B coverage for doctors’ visits also have their premiums deducted from Social Security payments. Part B premiums are expected to rise as well. But under the law, the increase cannot be larger than the increase in Social Security benefits for most recipients.

There is no such hold-harmless provision for drug premiums.

Kennelly’s group wants Congress to increase Social Security benefits next year, even though the formula doesn’t call for it. She would like to see either a 1 percent increase in monthly payments or a one-time payment of $150.

The cost of a one-time payment, a little less than $8 billion, could be covered by increasing the amount of income subjected to Social Security taxes, Kennelly said. Workers only pay Social Security taxes on the first $106,800 of income, a limit that rises each year with the average national wage.

But the limit only increases if monthly benefits increase.

Critics argue that Social Security recipients shouldn’t get an increase when inflation is negative. They note that recipients got a big increase in January – after energy prices had started to fall. They also note that Social Security recipients received one-time $250 payments in the spring as part of the government’s economic stimulus package.

Consumer prices are down from 2008 levels, giving Social Security recipients more purchasing power, even if their benefits stay the same, said Andrew G. Biggs, a resident scholar at the American Enterprise Institute, a Washington think tank.

“Seniors may perceive that they are being hurt because there is no COLA, but they are in fact not getting hurt,” Biggs said. “Congress has to be able to tell people they are not getting everything they want.”

Social Security is also facing long-term financial problems. The retirement program is projected to start paying out more money than it receives in 2016. Without changes, the retirement fund will be depleted in 2037, according to the Social Security trustees’ annual report this year.

President Barack Obama has said he would like tackle Social Security next year, after Congress finishes work on health care, climate change and new financial regulations.

Lawmakers are preoccupied by health care, making it difficult to address other tough issues. Advocates for older people hope their efforts will get a boost in October, when the Social Security Administration officially announces that there will not be an increase in benefits next year.

“I think a lot of seniors do not know what’s coming down the pike, and I believe that when they hear that, they’re going to be upset,” said Sen. Bernie Sanders, an independent from Vermont who is working on a proposal for one-time payments for Social Security recipients.

“It is my view that seniors are going to need help this year, and it would not be acceptable for Congress to simply turn its back,” he said.

Because of its size and cost, Medicaid has been called the “workhorse” of the U.S. health system. Now it’s front and center in the debate on overhauling the U.S health system and expanding coverage to the uninsured.

With 60 million enrollees, Medicaid dwarfs other insurance programs, including its cousin, Medicare, which covers 44 million elderly and disabled people.Medicaid is a joint federal-state program, with the federal government picking up about 57 percent of the overall Medicaid tab. But the federal contribution varies by state, ranging from 50 percent to 73 percent, with poorer states getting a bigger matching rate.

Medicaid isn’t a one-size-fits-all program; after meeting certain federal requirements, each state has the flexibility to shape coverage and benefits. As a result, the Medicaid program in Pennsylvania bears little resemblance to the one in Louisiana. For example, non-working parents in Pennsylvania qualify for Medicaid if their incomes are below twice the federal poverty level ($44,100 for a family of four). But in Louisiana, non-working parents qualify only if their incomes are below 11percent of the poverty level ($2,426 for a family of four). States frequently experiment with new concepts in benefit design, eligibility and delivery systems.

In general, Medicaid covers about 45 percent of poor Americans, defined as those with incomes below the federal poverty level (about $22,000 for a family of four). To be eligible for coverage, individuals must fall below certain income thresholds, which vary by state, and belong to certain categories, such as having dependent children, or being pregnant or disabled. In 20 states, a parent in a family of four who gets paid the federal minimum wage makes too much to qualify. Only 18 states cover adults without dependent children.

Medicaid benefits include mental health services, transportation-to-health services, and comprehensive screenings and treatment for children. In addition, Medicaid enrollees have much lower out-of-pocket costs than people with private coverage. There are typically no monthly premiums and no, or very low, co-payments

However, in many states, specialists and dentists don’t see Medicaid patients. Providers typically blame low reimbursement rates as the main reason for not accepting Medicaid patients. In Kentucky, Medicaid pays doctors $210for a colonoscopy; Medicare pays $333. Private insurers usually pay more. In Pennsylvania, Medicaid pays doctors $300 for an appendectomy, while Medicare pays $575.

About 76 percent of all enrollees are children and their parents. And 65 percent of people on Medicaid come from working families. About three quarters of Medicaid spending is for the elderly and disabled, even though the two groups make up only about one quarter of the program’s enrollees. Medicare provides little coverage for long-term care, so many elderly, after depleting their savings, rely on Medicaid to pay their costly nursing home bills.

Administrative costs of Medicaid are less than 7 percent, or half the rate that’s typically seen in the private sector. Medicaid holds down costs in part by paying providers lower fees and doing little marketing.