Americans had better brace themselves for a brutal fight over the future of the federal government's major health-care programs.
Hardly a week goes by without someone pointing to Medicare and Medicaid as major targets of those seeking to balance the budget without increasing taxes.Likewise, hardly a week goes by without those trial balloons attracting flak from powerful sources.
Part of the criticism comes from medical professionals who fear that cuts in Medicare and Medicaid would not only hit them in the pocketbook, but also impair the quality of health care.
Even more opposition comes from key congressional leaders who fear a political backlash from the 33 million elderly Americans who qualify for Medicare and the 22 million poor who qualify for Medicaid.
Medicare took a budget hit last fall in the government's deficit reduction plan, and Congress is balking at another cut.
But President Bush can't put federal health-care programs off limits to budget cutters without endorsing more tax hikes, imposing disproportionate cuts on other federal operations or tacitly embracing the deficit as a permanent fixture.
Politics aside, the case for taking a close look at possible cuts in Medicare and Medicaid is compelling. The size of these programs - Medicare alone amounts to $104 billion - makes them obvious targets.
The government's medical-care costs have been rising at two to three times the general rate of inflation. The rapid escalation of government and private spending on health has risen to the point where it now constitutes 11.1 percent of the U.S. gross national product, the highest of any major developed nation.
Unless corrected, this situation seems bound to grow worse as the aged constitute an increasing portion of the U.S. population and as the higher incomes of new retirees entitle them to larger medical benefits than their predecessors.
Is there no way to come to grips with the mounting cost of federal medical programs without seriously eroding the quality of medical care or needlessly antagonizing substantial segments of the population?
For openers, how about adopting a uniform national fee schedule for physician services under federal health programs? As it is now, each doctor has a schedule based on his or her own history of fees.
But a uniform schedule could be used to keep a tight control on how fast fees are allowed to rise and how much doctors would be allowed to expand the volume of services they perform per Medicare patient. The Congressional Budget Office estimates this change would save $27 billion over five years.
How about abolishing the ceiling ($48,000 in 1989) on the amount of wages subject to the Medicare portion of the Social Security tax? Such a change would save $35 billion over five years.
How about considering a means test, so that all with income over a certain amount would be ineligible for Medicare benefits?
Bush is proposing a tripling of premiums for Medicare Part B, which pays for doctor bills, for the 500,000 wealthiest Medicare recipients. Under the Bush plan, the 1992 monthly Medicare premium of $31.80 for single people would jump to $95.40 for those with an annual adjusted gross income of $125,000 or more. For couples, the threshold would be $150,000. The idea makes sense. People with those kinds of incomes surely can pay higher Medicare premiums.
Though zeroing in on Medicare may be painful, the fact remains that each successive effort to curtail federal spending becomes tougher than the previous one. If the federal deficit is ever to be eliminated, there comes a time when big and rapidly growing programs simply must be trimmed no matter how popular they are.