We are utterly unable as a nation to have an adult discussion about Medicare. The latest example is from Eric Bolling, who says "Obamacare may literally kill you", but let's be honest: nobody in their right mind wants to touch that third rail.
With the exception of Paul Ryan. Setting policy aside - because, let's be frank, that's not what figured in to his stance - the political calculus he made is very close to that of the Obama administration. His plan is a massive giveaway to the insurance industry, taking a gamble that the campaign money that can be pulled in from these deep pockets will more than make up for the political fallout from the "don't touch Medicare!!!" crowd.
The PPACA ("Obamacare") legislation was pretty much crafted on the same lines, in the end. No public option, certainly no move towards single-payer or away from tying health insurance to your job. It became a massive giveaway to insurance companies. Yes, there are key differences on the policy side: insurance companies gave up some things in the bargain, most importantly coverage for pre-existing conditions. But the political calculus? Pretty much the same.
Both dance around the 800 lb gorilla in the room: growth in costs. From 2000 to 2007, health care costs in the US climbed 14%. And health care already consumes 16% of GDP. The rate of Medicare growth per-patient is somewhat lower, at 3.1% per year, but that still means it doubles every 23 years.
The PPACA established the Independent Payment Advisory Board, due to make reccomendations in 2014 for containing costs. Its specifically prohibited from rationing care. But still, the right used it to create a tremendous furor over "death panels". No doubt that meme will be revived again when it issues a report. Even the most mild attempts at reining in costs are political suicide.
The unavoidable truth is that, in some way, care will have to be rationed. With some drug treatments hitting as much as $400,000 and numerous treatments for cancer running well in to six figures, the boank check can't continue. At some point, the adults in the room - on both sides - need to acknowledge this.
You can ration care in one of three ways: bureaucrats, insurance companies, or block grants.
With the first option, government makes the decisions. Their incentives are to control costs and minimize political uproar. Not a perfect solution, but perhaps the least bad of the bunch. But any Democrats who seriously propose this will be tarred and feathered. We mustn't deny a comatose 86 year old with multiple organs failing that expensive treatment that might extend life a few weeks or months, no matter what the cost. Because: killing grandma!
So most likely we'll paper it over. That's the Ryan plan: hand it over to insurance companies, and let them ration care. Since their only incentive is profit, don't expect medical efficacy to play much of a role in making decisions.
Or we can go with the Republican answer for Medicaid - block grants. That's the worst con job of all: let's declare goals, then pick an arbitrary number of dollars that won't remotely be enough to meet those goals, and hand the money to the states. The states make the tough choices, and can blame Congress. Congress can shrug and say, it was your choice. The buck stops where people end up dying frmo easily preventable or treatable illnesses.
And that's where we end up. In a rational world, we'd study outcomes for treatments for particular patient profiles - Medicare already gives us a wealth of data with which to do this - and draw a line on the chart. Below this level of effectiveness, Medicare doesn't pay.
And that means some people would die, who could otherwise have had their lives extended. That's the reality. We're in a nation that thinks an 80 year old's health is a sacred thing that must be protected at all costs, but a 20 year old woman, unless she's so very poor as to qualify for Medicaid (an income under $5,000 a year in many states), is on her own. And even the minimal health services she might receive from Planned Parenthood are under threat of defunding.
Nope, not an adult in sight. Our media model doesn't allow for a serious discussion: getting leaders from both sides in a room, and spending an hour or two asking them pointed questions about the hard choices. The public won't demand such a discussion, so we're not going to get one.
That, folks, either the Ryan plan (privatization) or block grants will be adopted. Probably the latter. As policy, they suck. But the political calculation is pure gold.