Medicare and Medicaid cost $627 billion last year - almost a quarter of all federal spending. That amount is expected to double within 10 years as baby boomers overwhelm the Medicare program. Yet you won't hear much on this subject from Sens. Hillary Clinton, Barack Obama and John McCain. They fear discussing it because all the conventional choices for reining in the cost of these programs are unpleasant. They include limiting care, raising taxes, reducing payments to providers and asking wealthier beneficiaries to pay more.
As Eugene Steuerle of the Urban Institute has noted, a typical baby boomer couple retiring in 2020 will have paid about $100,000 in lifetime Medicare taxes - and will receive about $500,000 in lifetime Medicare benefits. The program's hospital insurance trust fund is expected to go broke in 11 years.
The Congressional Budget Office attributes much of the rise in costs to beneficial but expensive new medical technologies. Many experts believe entitlement spending can only be controlled by slowing the growth of overall health care spending.
Unfortunately, the major candidates' plans for reducing health costs don't inspire confidence. Mr. Obama speaks of switching to electronic records and increasing competition in the insurance and drug markets, which may help some. Mr. McCain offers a raft of small-bore policy ideas centered around giving individuals more control over spending; it's hard to see how that would restrain costs. Mrs. Clinton has little to say about holding down expenses.
But candidates who seek to expand health coverage shouldn't find it so difficult to talk about tamping down costs. Many health advocates argue persuasively that extending health coverage to more people will reduce costs, because the insured are more likely to avert costly illnesses through preventive care. They also don't rely on expensive emergency room visits for routine treatment, as the uninsured often do.
Pointing out the connection between expanding coverage and controlling costs may be a "safe" way for skittish politicians to broach this uncomfortable subject - even during an election year. It's a conversation the nation can't afford to put off.
