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The basic trouble with health care is simple -- and disagreeable.
Our reluctance to face this fundamental problem is preventing a truly frank debate over how to control runaway health care costs that are pushing America toward economic crisis.
A debate of sorts is underway, of course, largely between President Obama and Republican Rep. Paul Ryan of Wisconsin, chair of the House budget committee.
Focused on the ruinously mounting costs of the federal government's big health care programs -- Medicare and Medicaid -- their faceoff is a good thing so far as it goes.
Unfortunately, the discussion quickly goes in circles thanks to a nearly universal eagerness to ignore the big tragic reality about health care.
What I mean is absurdly obvious, but apparently it needs to be said: The basic trouble with health care is that it always fails in the end.
Naturally enough, what people want from health care is health -- and life. Yet what each of us gets, sooner or later, is sickness and death. Until there is more sign of this ultimate grim reality changing, the cost of chasing the rainbow's end can only grow.
It's worth noticing that we don't have quite this problem with other good things we desire. At least in an advanced economy like America's, we can produce enough food, enough housing, enough clothing, enough cell phones (and then some).
It's human nature to always want more and better, but in most things basic needs can be met and people can be left to decide how much of their incomes to spend on various things.
We have inequality and poverty problems. Not everyone can afford the food or clothing or housing they need.
But the difference is that with health care, no one, in the end, can get their most basic need met. Bill Gates and Warren Buffett, with all their billions, will eventually be unable to buy another day of wellness or life.
Foolishly obvious, yes -- but we seem to be missing what this means.
Even though we can't satisfy the demand for health, the health care industry can and does supply an endless cornucopia of treatments, drugs, devices, surgical techniques and therapies. Many of these are wonderful, extending and improving lives.
Others provide more marginal and temporary benefits. Some are breathtakingly expensive, others pretty cheap -- and sometimes the cheap ones give more benefit to more people than do the costliest.
But because the supply of health care services just keeps expanding, without conquering sickness and death, there is no place for spending to stop increasing. Unless, somehow, we decide when enough is enough.
This is the real, painful challenge of health care reform. To limit costs ultimately has to mean limiting care.
How to limit care most wisely and justly -- through central regulation, market competition, or some blend -- is the real debate we should be having. But we're stuck trying to convince one another that only the "other side" would ever think of asking anybody to give up anything in health care.
In his deficit speech earlier this month, Obama said the health reform law passed last year will "drive greater efficiency" and "reduce unnecessary spending" largely because it will "change the way we pay for health care."
And if costs continue to soar, despite this much-discussed miracle cure of "payment reform"? Then, Obama said, "this approach will ... make additional savings by further improving Medicare."
Further improving Medicare? That's our last resort, if all else fails?
Ryan was equally in denial in a recent newspaper column. He wrote that his plan to essentially privatize federal health programs by turning them into voucher systems was all about "using competition to weed out inefficient providers, improve the quality of health care for seniors and drive costs down."
We won't feel a thing.
Yet Obama and Ryan, with their sugar-laced euphemisms, aren't the only ones recoiling from facing facts. Commenting on the competing cost-cutting plans, the New York Times worried that "it is not clear that ... goal can be met without harming providers or beneficiaries."
The Economist fretted that it could mean "reducing the quality of care or passing more costs along to patients."
It's enough (almost) to make you pity the politicians -- this apparent need to pretend that efficiency or accountability or purchasing power or competition or some magic incantation can cut trillions of dollars from future health care spending (because that's what we have to do) without denying anybody care, or costing anybody more, or even pinching providers (unless they're "inefficient").
The bomb-throwers warning of "death panels" were, after all, onto something. However crudely, they at least confronted the truth that limiting costs means asking people to make peace with unwelcome limits to what we can accomplish in health care.
That their concerns were labeled not just exaggerated but utterly ridiculous showed that America is not yet ready for a serious health care debate.
No doubt great efficiencies in health care could be found. Finding them will be the secret to enjoying all the health-improving wonders America can actually afford.
But until this debate more openly confronts the fact that what we can afford in health care has boundaries, it will hardly be worth having.
D.J. Tice is the Star Tribune's commentary editor.
The Opinion section is produced by the Editorial Department to foster discussion about key issues. The Editorial Board represents the institutional voice of the Star Tribune and operates independently of the newsroom.