President Bush is supposed to give the details today on how he proposes to deliver health care to the American people without pulverizing what is left of a thoroughly busted budget. His plan will be blasted by Democratic opponents who are pushing two alternative approaches in an election-year struggle over an issue that ranks at the top of voter concerns. Both parties, we suspect, will emphasize what goodies they have to offer. Both parties, we further suspect, will range from mute to circumspect on how they plan to pay for it.
Yet paying for health care ranks right up there with reforming the health-care system as the most important budgetary problem confronting this country. The two issues are linked inextricably. Medicare and Medicaid, two federal programs that entitle mostly elderly or poor people to both federal and state assistance in meeting their health bills, are rocketing skyward on a trajectory that leaves even the defense budget far behind.
Mandated federal programs -- mostly Medicare, Medicaid, unemployment compensation and farm price supports -- account for $766.8 billion in the new Bush budget. That is approximately half the entire $1.52 trillion spending plan the president has proposed and far more than double the proposed $281 billion defense budget.
There are no real controls on this entitlement spending. Congress keeps adding strands to the safety net and once they are part of the fabric nothing can rip them out. Instead, government costs are determined by such outside factors as population growth and aging, birth rates and the state of the economy. As recession drops more people into poverty, federal and state governments have to pay out more and more money.
President Bush and Budget Director Richard Darman have called for "a mechanism that limits the growth in aggregate mandatory spending" to parallel curbs on discretionary spending imposed by the 1990 budget agreement. Otherwise, the sky's the limit. Entitlement costs have gone from $32.3 billion in 1962 to $766 billion for 1993. Medicaid alone is up 17 percent over a year ago, and is crunching both state and federal budgets.
Mr. Darman estimates that if entitlement costs merely reflected population growth and the inflation rate, projected mandatory government spending in the next five years would be reduced by a "shocking" $390 billion -- perhaps enough to bring the budget into balance. Even with a few softening add-ons, this is just not enough for some free-spending Democrats. They portray such controls as evidence of Republican callousness but neglect to point out how stratospheric deficits skew distribution of wealth in favor of the rich.
We have no illusions that health-care reform or health-care financing will be responsibly dealt with by the Washington establishment in this campaign year. But just to get these subjects on the national agenda will be an accomplishment. They cannot be bypassed much longer.