The sharp knives are out for the Medicare program.
They are likely to succeed. Any entitlement program that now costs nearly $150 billion and is projected to increase by $100 billion more in five or six years would be similarly targeted for budget cuts.Yet the more important victim of the budget pressure is likely to be badly needed improvements in long-term and home care for the aged.
They may not even have a chance in the future. How can we pay for both? We probably can't (or won't), but there is a possible solution.
Why not allow the elderly to choose their own balance between high-technology curative medicine on the one hand and low-technology caring medicine, long-term care and social support on the other?
The aim of curative medicine - the heavy bias of the Medicare program - is to save and extend life.
There is fine coverage for a heart attack and time in an intensive-care unit but terrible coverage for the frail person unable to manage the ordinary demands of life by herself.
Caring medicine shifts the emphasis to primary care, comfort and palliation, to maintaining independence as long as possible and to providing social and economic support.
Part A of the Medicare program provides hospitalization. Part B provides physician care.
A new part - call it "Medicare: Part C" - could give the elderly the voluntary option of exchanging their mandated right to acute-care coverage for extended long-term and home care coverage.
At a specified age, say 75 or 80, elderly persons could choose restricted hospital benefits and receive in turn enhanced quality-of-life benefits.
The elderly would be allowed to balance the two forms of coverage in any way they saw fit.
A plan of this kind would encounter strong obstacles. It is possible that, after all the economic calculations are made, the new plan could significantly increase costs, thus intimidating legislators.
It could also seem to be a premature capitulation to economic and ideological forces that now, but not necessarily forever, make it hard to introduce a better long-term care policy without cutting into acute care coverage.
It could, in addition, seem coercive to some elderly people, who would not want to have such a choice or not know how to make it.
These are serious but not insuperable obstacles. Medicare: Part C should offer a range and variety of choices, not demanding just one way of balancing the benefits.
The basic Medicare program should offer good primary and emergency care and good public health services; palliative care in the face of death would be imperative.
It should be the right of the elderly to decide, in the face of potent forces likely to cut their benefits in the years ahead, to have the kind of health care they want and choose.