In December 8, President George W. Bush signed into law a bill that will provide drug benefits under Med­i­care. Supporters have hailed the measure as a groundbreaking step. Opponents have criticized it on two grounds-for being too modest in the help it will provide seniors and for capitulating to lobbyists representing insurance companies and private health plans.

Both Republicans and Democrats agree about the desirability of including drugs in Medicare coverage, but their different approaches to effecting that change reflect deeper divisions about the role of government in health-care policy. Senator Ted Kennedy (D-Mass.) believes that providing the benefit through private insurers is the opening wedge in an effort to privatize Medicare. He fears that such a fundamental change will lure younger and healthier seniors into private plans, thereby shrinking the pool and leaving sicker, more vulnerable seniors to pay higher premiums for the traditional program. Senate Majority Leader Bill Frist (R-Tenn.) wants to introduce greater competition in the Medicare market. He favors “premium support,” in effect tax-based vouchers for seniors to shop around among qualified plans and choose the one that best meets their individual needs. In doing so, he hopes to provide greater innovation and flexibility in the health-care choices of seniors and to reduce the costs of Medicare over time.

The claims of both sides seem simplistic. Kennedy is right to note that the logic of Medicare as an entitlement would change with the introduction of private plans. Yet he fails to acknowledge the inevitable increase in costs, beginning in 2010, as Baby Boomers in significant numbers begin to collect their benefits. Medicare costs will be further exacerbated with the addition of a drug benefit, since nothing in the current proposal is designed to rein in the soaring prices of pharmaceuticals. Still, Frist’s faith in the cost-containing capacities of privatization seems equally dubious. Health maintenance organizations, claiming they cannot make a sufficient profit, have been leaving the Medicare market since 1999, forcing tens of thousands of seniors to find new medical providers. To repeat, costs are likely to increase significantly, yet the bill specifically prevents the federal government from using its leverage to negotiate lower prices with drug companies. There is little evidence to suggest that most private plans, which are profit driven and bloated with administrative overhead, will achieve greater efficiencies than traditional Medicare. With health-care cost inflation back in double digits and with 44 million persons lacking health insurance, it seems more sensible to many analysts to try to make the rest of health-care delivery resemble traditional Medicare rather than the reverse.

I am less concerned with the details of the current law than with what the debate reveals about our continuing collective denial of the facts about medical care in this country. Neither side is willing to acknowledge the elephant in the middle of the legislative chamber. Whether we restructure Medicare or attempt to reform health-care delivery more broadly, we have yet to address hard political and medical choices. The late Cardinal Joseph Bernardin expressed a conviction central to several recent Catholic analyses of health care; he described such care as “an essential safeguard of human life and dignity,” one that obligated society “to ensure that every person be able to realize this right.” As sentiments go, that is a noble one, but in order to guarantee universal access to “basic” care, we must determine reasonable limits to the scope of that care. There are other important social goods being crowded out by health-care spending, which currently constitutes 14 percent of our gross domestic product. And there are obvious inefficiencies and perverse incentives in the mix of public and private financing at work in the current system. Whatever one’s preferred solution to lack of access and to controlling costs (single-payer, tax-based vouchers, a continued mix of public and private dollars, an expanded employer-based model), the issue of fair and responsible limits-on spending or services or both-will be crucial to any blueprint for reform.

We chafe at the notion of limits or, to use the forbidden word, rationing. Yet we already ration health care-by ability to pay, by the luck of the employment draw, by the mix of providers available in a given region. In large measure, our health-care policy has been driven for more than three decades by what one analyst calls an “ideology, a collective illusion.” For too long, we have pretended that all citizens can receive the best of care, equal care, with unlimited choice of provider, and without excessive costs. We should reject that illusion and seek justice instead. Consider Medicare itself. It has always provided only limited coverage. Most Medicare recipients have some form of Medigap insurance for services and costs not covered by the traditional program. The proposed drug benefit, at $400 billion, is estimated to cover only 22 percent of the costs of drugs for seniors during the next decade. The idea that drugs or eyeglasses or home health care can be added without attending to the question of reasonable limits on cost is ludicrous. Health care should be a right; Catholic social teaching and much of secular thought affirm that commitment. Yet as a positive right, health care is necessarily constrained by other social needs. The key question, one hardly addressed in the recent debate and seldom acknowledged by the advocates of universal access, is how to determine-fairly and openly and honestly-what limits we are willing to accept in order to assure access to basic care for everyone. Until we answer that question, we will not have effective reform, nor will we fulfill the practical requirements of justice. end