It's become a regular exercise in budget brinksmanship. Medicare is again warning that doctors face draconian pay cuts on Jan. 1 unless Congress acts.

Officials said Tuesday it works out to a 27.4 percent cut.

No one expects lawmakers to allow the axe to fall, but 48 million beneficiaries and their doctors are looking on nervously.

Temporary reprieves have created a recurring problem that gets harder and harder to fix. A 1990s budget law called for automatic cuts to doctors if Medicare costs kept rising. Congress has issued so many waivers that a permanent fix would now cost more than $300 billion over 10 years.

A nonpartisan panel advising lawmakers recommends a 10-year freeze for primary care doctors and cuts followed by a freeze for specialists. Doctors aren't buying that.