1 See Theodore Marmor & Jerry L. Mashaw, The Future of Entitlements: How “Future Dread” Distorts the Debate Over Social Security Pensions and Medicare, in The Oxford Companion to Politics of the World (2d ed., forthcoming Nov. 2001) (arguing that the claim that American social policy is unaffordable, unmanageable and undesirable is factually questionable, interpretively misleading and widely disseminated).

2 See Thomas B. Edsall, The Gop's Flawed Fable: The Miracle of Michigan Traps the Party's Thinking, WASH. POST, Jan. 21, 1996, at CI; Norman Ornstein, Dems, Beware of Medicare: Seizing on GOP Quandary Could Backfire in the Long-Term, USA Today, June 1, 1995, at 11A.

3 The muddle encompasses different perceptions of Medicare's problems and proposed solutions to them. For some policymakers, the main problem is a shortage of future revenues. As Health and Human Services Secretary Donna Shalala put it, “There is simply no substitute for more money to come into the system.” Stephen Nohlgren, Lawmakers Lobby for Reform of Medicare at USF Forum, ST. Petersburg Times, Oct. 12, 1999, at IB. For others, the problem is more fundamental. “I think putting surplus dollars into the Part A Trust Fund doesn't fix Medicare's underlying problem. I've likened it to putting more gas in an old car—it still runs like an old car and doesn't have any of the features of a new car.” John Breaux, Opening Statement: Medicare Commission (visited May 12, 2000) <http://rs9.loc.gov/medicare/breaux31699.html>. Similarly, reforms such as proposals to introduce “competition” into the program provoke widely divergent reactions. A New York Times story about one such proposal, a bill introduced by Senator John Breaux (D-LA), illustrates such competing perspectives:

Michael M. Weinstein, For Medicare, A Rocky Road To Competition, N.Y. Times, Feb. 21, 1999, at § 3, 1. Even the basic premises of proposed reforms are contested. Representative John D. Dingell, Cdmi) worries that Senator Breaux's proposal “would convert Medicare from a universal guarantee to a government voucher for private insurance.” Robert Pear, Medicare Panel, Sharply Divided, Submits No Plan, N.Y. Times, Mar. 16, at Al. This view was flatly denied by the plan's sponsor. “This proposal is not a voucher program,” he said “It is not an end to Medicare as an entitlement.” Id.

4 The narrative history sketched in Sections II and III of this Article draws upon the more extensive analysis of Medicare's origins and operations detailed in Theodore R. Marmor, the Politics of Medicare (2d ed., 2000).

5 Medicare is the federal health insurance program for the aged and disabled established by Congress as Title XVIII of the Social Security Act. 42 U.S.C. § 1395 (1994).

6 See Theodore R. Marmor, Coping with a Creeping Crisis: Medicare at Twenty, in Social Security: Beyond the Rhetoric of Crisis 177, 178 (Theodore R. Marmor & Jerry L. Mashaw eds., 1988).

7 See id.

8 For example, in both Germany and England, government-sponsored health insurance began in the late 19th and early 20th centuries as a government mandated membership in preexisting mutual benefit funds. Seen as a way to maintain the incomes and productivity of the working class, it was originally limited to wage earners. See Paul Starr, The Social Transformation of American Medicine 237-40 (1982).

9 From this starting point, Canada went to universal programs for one service (hospitals) and then shifted to another (physicians). See Theodore R. Marmor, Can the U.S. Learn from Canada?, in National Health Insurance: Can we Learn From Canada? 231, 233-41 (Spyros Andreopoulos ed., 1975).

10 There were a number of reasons why health insurance failed to be enacted during this period, including the fact that national health insurance was portrayed by opponents as a German concept inconsistent with American values. See Starr, supra note 8, at 253 (quoting a pamphlet written in 1917 by a group of California physicians that describes compulsory social health insurance as “a dangerous device, invented in Germany, announced by the German Emperor from the throne the same year he started plotting and preparing to conquer the world").

11 See id. at 266-69.

12 See id. at 282-84.

13 See MARMOR, supra note 4, at 6-10.

14 See id. at 23.

15 See id. at 10-11.

16 See id. at 17.

17 See id. at 10; see also Marmor, supra note 6, at 179.

18 See MARMOR, supra note 4, at 95-96.

19 For a more detailed discussion of the Congressional fight over the enactment of Medicare and the expansionist aspirations of its supporters, see generally Sheri David, With Dignity: The Search for Medicare and Medicaid (1985), Lawrence Jacobs, the Health of Nations: Public Opinion and the Making of American and British Health Policy (1993), and Marmor, supra note 4. The basis for the presumption of Medicare's architects' views about future expansion is largely Marmor's service as Wilbur Cohen's special assistant the summer of Medicare's operational start in 1966.

20 Indeed, the first section of the Medicare statute is entitled “Prohibition Against any Federal Interference,” and states:

42U.S.C. § 1395(1994).

21 See Jacobs, supra note 19, at 94, 148.

22 See id. at 94.

23 See id. at 90.

24 See id. at 152-53, 206-07.

25 See 42 U.S.C. § 1395d (1998).

26 See id. § 1395k.

27 See Marmor, supra note 4, at 12-13.

28 See id. at 97.

29 See id.

30 See id.

31 Although Medicare is a federal program administered by the Health Care Financing Administration (HCFA), within the federal Department of Health and Human Services, much of the day-to-day running of Medicare is carried out by private insurance companies under contract to HCFA. These companies, known as “fiscal intermediaries” (Part A) or “carriers” (Part B), process claims, and make coverage and payment decisions. For a more extended discussion see MARMOR, supra note 4, at 95-99.

32 See id.

33 See STARR, supra note 8, at 375-76.

34 See id.

35 See id.

36 See supra note 20 and accompanying text.

37 See infra notes 65-68 and accompanying text.

38 See MARMOR, supra note 4, at 97-99.

39 See id. at 98.

40 See id. (noting that the rate of physician fees more than doubled in the year between enactment of Medicare and its original operation).

41 See Marian Gornick et al., Twenty Years of Medicare and Medicaid: Covered Populations, Use of Benefits, and Program Expenditures, in Health Care Fin. Rev. 13,43 (Ann. Supp. 1985).

42 See id. at 36.

43 See, e.g., Theodore R. Marmor et al., America's Misunderstood Welfare State: Persistent Myths, Enduring Realities 178-85 (1990) (describing the change from the 1960s, where the lack of access to health care for portions of the population was viewed as the major concern of the American health care system, to the 1970s, where dramatically spiraling health care costs became the major concern).

44 See id. at 180.

45 See id. at 182-83 (discussing actions indicating the government's movement toward universal health insurance coverage).

46 See id. at 186-87 (explaining various reimbursement schemes such as increasing deductibles, co-insurance and cost sharing between employer and patient-employee, as well as increased use of health maintenance organizations (HMOs) and Preferred Provider plans to contain costs).

47 See 42 U.S.C. § 426(b) (1994) (extending Medicare coverage to certain people with disabilities who are under age 65); Id. § 426-1 (1994) (extending Medicare coverage to people under age 65 who suffer from end-stage renal disease).

48 Medicare was initially administered by the Bureau of Health Insurance within the Social Security Administration of the Department of Health, Education and Welfare. See Timothy S. Jost, Governing Medicare, 51 Admin. L. Rev. 39, 86 (1999). In 1977, Congress created HCFA as a separate agency to administer Medicare. See id.

49 See MARMOR, supra note 4, at 17-21, 77-78 (discussing the growth of special interest groups arising from early cleavages within the Medicare debate).

50 See David S. Broder, Major Reorganization Announced for Hew, WASH. POST, Mar. 9, 1977, atAl.

51 See Matt Clark et al., Health Care Battle, Newsweek, May 28, 1979, at 28, 29.

52 See James A. Morone & Theodore R. Marmor, Representing Consumer Interests: The Case of American Health Planning, in Political Analysis and American Medical Care 76, 77 (Theodore R. Marmor ed., 1983); Theodore R. Marmor & Morris Barer, The Politics of Universal Health Insurance: Lessons for and from the 1990s, in Health Politics and Policy, at 306, 309-10 (Theodor J. Litmar & Leonard S. Robins eds., 3d ed., 1997).

53 After the Carter administration's attempts to secure passage of legislation that explicitly regulated hospital costs was blocked, the hospital industry adopted a “voluntary effort” to control spending. This voluntary effort, however, was a disappointment in practice. See Mark A. Peterson, Interest Groups as Allies and Antagonists: Their Role in the Politics of Health Care Reform (1995) (unpublished manuscript, on file with author).

54 See Clark, supra note 51, at 29.

55 See Table 1, infra at 250.

56 See id.

57 See Theodore R. Marmor & Jerry L. Mashaw, Social Security: Beyond The Rhetoric of Crisis 190(1988).

58 See Jost, supra note 48, at 67-70.

59 See id.

60 See id.

61 With the enactment of the Social Security Amendments of 1983, Pub. L. No. 98-21, 97 Stat. 65 (1983), the manner in which hospitals were to be paid for providing services to Medicare beneficiaries was changed from a “reasonable cost” basis to a “prospective payment” system, where the hospital would be paid a fixed amount depending upon the patient's diagnosis. For a detailed discussion of this change see generally Frankford, David M., The Medicare DRGs: Efficiency and Organizational Rationality, 10 Yale J. on Reg. 273 (1993)Google Scholar.

62 See 42 U.S.C. § 1395w-4 (1988 & Supp. 1989).

63 See Figure 1, infra at 252; Marylin Moon, Medicare Now and in the Future 19 (2d ed. 1996).

64 The point here is not that these measures were necessarily misguided or should have been avoided because of the increasingly zero-sum nature of the conflict they helped foster. Rather, it is simply that the heightened zero-sum politics created different, if quite predictable, conflicts than had been the case in the earlier period of accommodation.

65 See Henry J. Aaron & Robert D. Reischauer, “Rethinking Medicare Reform ” Needs Rethinking, Health Aff., Feb. 1998, at 69, 69.

66 See Marmor, supra note 4, at 123.

67 See generally Lawrence R. Jacobs et al., The Polls—Poll Trends: Medical Care in the United States—An Update, 57 Pub. Opinion Q. 394 (1993) (giving the results of public opinion polls regarding health care issues in the 1992 presidential campaign).

68 The Medicare Catastrophic Coverage Act of 1988, Pub. L. No. 100-360, 102 Stat. 683, was enacted in June 1988, became effective on January 1, 1989, and was terminated on November 30, 1989 by the Medicare Catastrophic Repeal Act of 1989, Pub. L. No. 101-234, 103 Stat. 1979. For a discussion of this process and its effectt on Washington policymakers, see generally Richard HlMelfarb, Catastrophic Politics: the Rise and Fall of the Medicare Catastrophic Coverage Act of 1988 (1995); Paul Light, Still Artful Work (2d ed., 1995).

69 See Point Counterpoint, At Issue: Would Bush Plan Gut Medicare Benefits?, L.A. Times, Sept. 3, 1992, at Al9.

70 Clinton said “President Bush's budget would gut Medicare benefits, making 'elderly people and their children pay more for basic health care.'" Id.

71 See Marmor, supra note 4, at 124.

72 See Cathleen Decker, Bush's Cuts Aimed at Sick, Elderly, Clinton Charges, L.A. Times, Sept. 2, 1992, at A6.

73 See id.

74 See generally Jacob Hacker, The Road to Nowhere (1997) (discussing the development and policy choices of President Clinton's health reform proposal); Theda Skocpol, Boomerang (1996) (analyzing the battle over the Clinton Health Security Act); Marmor & Barer, supra note 52, at 310-15.

75 Under the Republican proposal, Medicare beneficiaries would receive a voucher to purchase health insurance from the private insurance market, and this would replace the government-organized insurance Medicare currently provides. See Theodore Marmor & Jonathan Oberlander, Rethinking Medicare Reform, Health Aff., Jan.-Feb. 1998, at 52, 53.

76 Balanced Budget Act of 1997, Pub. L. No. 105-33 § 4021, 111 Stat. 251, 347 (1997) (establishing a bipartisan commission charged with examining the Medicare program and making recommendations to strengthen and improve it for the future).

77 See National Bipartisan Commission on the Future of Medicare (visited May 12, 2000) <http://thomas.loc.gov./medicare/index/transcripts.html> [hereinafter Medicare Comm 'n Web Site].

78 See 1995 Annual Report to the Board of Trustees of the Federal Old-Age and Survivors Insurance and Disability Insurance Trust Funds (visited May 12, 2000) <http://www.ssa.gov/history/reports/trust/1995/trdoc.html>. As described more fully infra at note 170, Part A of Medicare, like the Social Security program on which its financing was modeled, is funded through payroll taxes earmarked for an accounting trust fund. There are six “Medicare Trustees” who review that trust fund, and make annual reports to Congress.

79 In the language of the actuaries, that would take place when trust fund reserves would no longer be sufficient to pay the program's promised benefits. Projections by the trustees of impending trust fund insolvency have regularly triggered Medicare “crisis” talk. For an analysis of the regularity with which looming shortages in the Part A trust fund have translated into crisis responses by Medicare policymakers, see Jon Oberlander, Medicare and the American State (unpublished Ph.D. dissertation, Yale University 1995) (on file with UMI Dissertation Services, University of Michigan).

80 See Kenneth J. Cooper, Gop's Medicare Pilch Faces a Tough Crowd on the Road, WASH. POST, Aug. 15, 1995, at Al.

81 See Robert Dodge, Republicans Push Vote on Senate Budget Plan. Democrats Force Delays, Dallas Morning News, Oct. 28,1995, at 1A.

82 See GOP Response Signals Bipartisan Cooperation, Orlando Sentinel, Dec. 29, 1996, at Al.

83 See Balanced Budget Act of 1997, Pub. L. No. 105-33, 111 Stat. 251.

84 See Bill Walsh, Lott Endorses Market-Oriented Medicare Reform; Breaux Drops Push to Raise Eligibility Age, Times-Picayune, May 27, 1999, at Al .

85 See Robert Rosenblatt, Medicare Panel Fails to Adopt Rescue Plan, L.A. Times, Mar. 17, 1999 at Al . See generally Medicare Comm'n Web Site, supra note 77, (providing the Commission's final recommendations and transcripts of its hearings). Stalemate was made more likely by the Commission's ground rules requiring a super-majority (at least 11 of 17 members) to transmit a formal proposal to the Congress and the President. See id. With seven of the Democrats firmly opposed to the Breaux-Thomas plan, no such supporting coalition could be crafted. See Rosenblatt, supra at Al.

86 See Editorial, Breaux Plan a Threat to Medicare, Omaha World-Herald, June 7, 1999, at 7.

87 See id.

88 See Joseph White, “Saving” Medicare—From What?, in Understanding Long-Term Medicare Cost Estimates (forthcoming 2000).

89 See Marmor & Oberlander, supra note 75, at 54 (describing the politics and policy implications of voucher proposals); see also Aaron & Reischauer, supra note 65, at 69; Stuart M. Butler, Medicare Price Controls: The Wrong Prescription, Health Aff., Jan.-Feb. 1998, at 72, 73.

90 See National Bipartisan Commission on the Future of Medicare, Building a Better Medicare for Today and Tomorrow (visited May 12, 2000) <http://medicare.commission.gov/medicare/bbmtt31599.htm1>; see generally Thomas Richard Olivor, Conceptualizing the Challenges of Public Entrepreneurship, in The Integration of Psychological Principles in Policy Development 5 (Chris E. Stout ed., 1996) (providing a comprehensive discussion of the role entrepreneurship has played in recent health care and Medicare reforms such as the Oregon Health Plan, the growth and expansion of HMOs and the growth and development of grass roots organizations).

91 See Ramon Castellblanch, Medicare's Critical Condition, In These Times, May 2, 1999, at 12, 12.

92 See John F. Hams & Eric Pianin, Parties Swap Fire on Medicare: Details of Plans Remain Hidden, WASH. POST, July 26, 1995, at A4; Robert Pear, Democrats Storm Out of Medicare Session, N.Y. TIMES, Oct. 3, 1995, at A20; Eric Pianin & Judith Havemann, Gingrich, Dole Attack Clinton Over Medicare Salvage Effort, WASH. POST, May 3, 1995, at A6.

93 See Mark A. Peterson, The Politics of Health Care Policy: Overreaching in an Age of Polarization, in The Social Divide 181, 219 (Margaret Weir ed., 1998).

94 See id. at 190-91.

95 See Roger Hickey & Thomas Bodenheimer, Vouchers Would Raise Costs: Breaux and Thomas May Argue that Competition Among Private Health Plans Will Control Costs. The Facts do not Support that Belief, FT. Lauderdale Sun-Sentinel, June 22, 1999, at 13A.

96 See Peterson, supra note 93, at 192-214 (discussing at length the Medicare reform debate between President Clinton and the GOP).

97 See id.

98 See id.

99 See Marmor & Oberlander, supra note 75, at 52.

100 See National Bipartisan Commission on the Future of Medicare, Building a Better Medicare for Today and Tomorrow (visited May 14, 2000) <http://thomas.loc.gov/medicare/bbmtt31599.html>.

101 Henry Aaron & Robert Reischauer, The Medicare Reform Debate: What is the Next Step?, Health Aff., Winter 1995, at 8.

102 See id.

103 Id. at 20.

104 Id. at 8.

105 See id.

106 Id. at 27-28.

107 See id. at 8.

108 Id.

109 Id.

110 Id. at 8-9.

111 Id. at 8.

112 Public finance economists are well known for not consulting public opinion findings or qualitative work on social beliefs from anthropology or social psychology. See Theodore Marmor, How We Got to Where We Are: American Health Care Politics, 1970 to 1990, in Understanding Health Care Reform 28, 28-30 (Theodore Marmor ed., 1994).

113 See Jacobs, supra note 19, at 192-200; Jacobs et al., supra note 67, at 394-427. See generally Karlyn Bowman, Public Opinion and Medicare Restructuring: Three Views, in Medicare: Preparing for the Challenges of the 21st Century 281 (Robert D. Reischauer et al. eds., 1998) (examining the significance of public support and public opposition to Medicare reforms).

114 Indeed, the public is remarkably willing to admit its lack of knowledge. For instance, a 1997 Washington Post/Kaiser Family Foundation/Harvard University poll found a full 53% of respondents willing to say they knew “very little” about Medicare. See Public Agenda, Medicare: Red Flags (visited Jan. 14, 1999) <http://www.publicagenda.org/issues/red_flags_detail.cfm?issue_type=medicare&list=l&area=2>.

115 See Section II of this Article.

116 See MARMOR, supra note 4, at 4-8.

117 See id. at 10-15.

118 SEE Marilyn Moon & Janemarie Mulvey, Entitlements and the Elderly: Protecting Promises, Recognizing Reality 35,89-127 (1996).

119 Aaron & Reischauer, supra note 101, at 9.

120 See Aaron & Reischauer, supra note 65, at 69.

121 See Marmor & Oberlander, supra note 75, at 59.

122 In fact, the Journal of Health Policy, Politics and Law devoted its entire October 1999 issue to the reasons for and implications of the managed care backlash. Readers interested in a wide range of scholarship devoted to the question of this backlash should read this issue. See generally 24 J. Health Pol., Pol*Y&L . 860(1999).

123 See Table 2 infra at 251, and Figure 2 infra at 253.

124 Another illustration of the ill-regard with which the public views the managed care industry comes from a 1998 Harris poll. In that poll, managed care firms ranked second from the bottom in terms of the public's positive feelings about them. Who was the bottom-dweller in that survey? Tobacco companies. See Robert J. Blendon et al., Understanding the Managed Care Backlash, Health Aff., July-Aug. 1998, at 80, 85; see also Lawrence R. Jacobs & Robert S. Shapiro, The American Public's Pragmatic Liberalism Meets its Philosophical Conservatism, J. Health Pol., Pol'y & L. 1021, 1024-25 (1999); Kaiser Family Foundation, National Survey on Medicare: The Next Big Policy Debate? (visited May 16, 2000) <http://www.kff.org/content/archive/1442/reform_cp.pdf> [hereinafter National Survey on Medicare].

125 For further analysis, see generally the October 1999 issue of the Journal of Health Politics, Policy and Law, supra note 122. In particular, see the following articles in that issue: Mark A. Peterson, Introduction: Politics, Misperception, or Apropos?; Gail R. Wilensky, What's Behind the Public's Backlash?; and Lawrence R. Jacobs & Robert Y. Shapiro, The American Public's Pragmatic Liberalism Meets its Philosophical Conservatism. See also Blendon et al., supra note 124, at 81.

126 See Table 2, infra at 251. When one considers the character of some of the other policy changes that the managed care backlash has helped produce, such as restrictions on insurers' ability to limit hospital stays after routine births, the odds increase that this alternative reaction will occur. See Eli Ginzberg & Miriam Ostrow, Managed Care—A Look Back and a Look Ahead, 336 New Eng. J. Med. 1018, 1018-20 (1997). Combine a general antipathy toward managed care firms with sympathetic target groups (new mothers, vulnerable patients) and the impulse toward restricting the practices of insurers fits with our general understanding of the ways in which lawmakers respond to public opinion. See generally R. Douglas Arnold, The Logic Of Congressional Action (1990) (discussing ways in which politicians anticipate and respond to the preferences of constituents and worry about the incidence of costs and benefits distributed across groups of voters). Despite the efforts of generational equity enthusiasts to paint the elderly as “greedy geezers,” senior citizens remain, as a group, closer to the new mothers/vulnerable patients end of the scale than to the greedy insurers end. See Jacobs & Shapiro, supra note 124, at 1024-25; National Survey on Medicare, supra note 124.

127 Note that Medicare is still quite popular among even the youngest cohorts. To say that younger voters are less supportive of Medicare is not to say that they are unsupportive of it. Solid majorities remain for the program, even among young adults. As for the measures of skepticism about the program's future, it is harder to say what such expressions of doubt mean. After all, one may like a program and still have doubts about its future. In that sense, expressions of skepticism do not provide meaningful direction for policy-making in the way that expressions of support and opposition do. As Bowman has argued, concern about a program's future and talk of crisis may be “simply a way for people to say to their elected legislators: 'Pay attention. This issue is important to me.'” Bowman, supra note 113, at 283. With these caveats in mind, we simply note that young adults show up as more skeptical than older adults. But skepticism among the latter age group is easy to find in the survey data as well. What the skepticism means remains open to debate, a debate that in our view is unlikely to be resolved without richer data. For a recent study that reports greater skepticism among other younger cohorts, see generally Robert J. Blendon, Public Opinion and Medicare Restructuring: Three Views, in Medicare: Preparing For The Challenges of the 21St Century, supra note 113, at 288,288. He found, for instance, that the under 30 cohort was the only one in which a majority of individuals predicted bankruptcy for Medicare. See id. at 290.

128 It is also the case that neither the size nor the direction of the differences has operated in the past as the resentment advocates would claim. According to one scholar of public opinion and the elderly, based on survey data from the National Election Study through 1988, “the nonelderly were consistently more likely to say the federal government spends too little on Social Security and health care, Medicare, or care for the elderly.” Laurie A. Rhodebeck, The Politics of Greed? Political Preferences Among the Elderly, 55 J. Pol. 342, 350 (1993). Given the increased conservatism of younger cohorts in recent years, we do not want to make too much of the patterns found by Rhodebeck. See Alan I. Abramowitz & Kyle L. Saunders, Ideological Realignment in the U.S. Electorate, 60 J. Pol. 634, 634 (1998). It is enough for our purposes simply to note that, in the not too distant past, younger cohorts seemed perfectly willing to support programs for the elderly.

129 This is a common criticism of the “generational equity” arguments popularized by advocates such as the Concord Coalition. Norman Daniels has put the argument succinctly:

Norman Daniels, am I my Parents' Keeper? an Essay on Justice Between the Young and the Old 18 (1988). On the need to realize that social insurance systems simultaneously distribute income among particular age cohorts and over the life cycle of given individuals, see generally Theodore R. Marmor et al, Social Security Politics and the Conflict Between Generations: Are we Asking the Right Questions?, in Social Security in the 21st Century 195 (Eric R. Kingson & James H. Schultz eds., 1997).

130 “Narrow” in the sense that younger voters are taking into account only the Medicare taxes they pay and the non-existent Medicare benefits they currently receive, without factoring into their assessment the burden they might bear to meet their aged parents' medical care costs in the absence of Medicare. For an interesting examination of the degree to which preferences across generations fit with such self-interested expectations, see generally Susan A. MacManus, Taxing and Spending Politics: A Generational Perspective, 57 J. POL. 607 (1995).

131 For more detailed discussions of the differences between younger and older individuals, see generally Christine L. Day, What Older Americans Think: Interest Groups and Aging Policy (1990); Christine L. Day, Older Americans' Attitudes Toward the Medicare Catastrophic Coverage Act of 1988, 55 J. POL. 167 (1993); Rhodebeck, supra note 128.

132 See Kaiser Family Foundation, National Survey on Medicare: The Next Big Health Policy Debate? (visited Jan. 13, 2000) <http://www.kff.org/content/archive/1442/reform_pr.html>. The 1998 poll by the Kaiser Family Foundation/Harvard School of Public Health found consistent gaps in knowledge about specific aspects of Medicare when respondents were divided by age. See id. Individuals age 65 and above knew more about Medicare's details than did those under age 65. See id. The most dramatic difference concerned knowledge about Medicare's non-coverage of prescription drugs: 63% of those 65 and older knew that Medicare generally does not cover prescription drugs, while only 22% of the younger cohort knew this. See id. On other specifics, the differences between age groups were less dramatic, generally in the range of 10 points or so. See id.

133 On the tendency for elected leaders to take action in the face of “action forcing crises” in social insurance programs, see generally R. Douglas Arnold, The Political Feasibility of Social Security Reform, in Framing The Social Security Debate: Values, Politics, and Economics 389-417 (R. Douglas Arnold et al., eds., 1998).

134 See Anthony Beilenson, Leadership and Politics: Four Views, in Medicare: Preparing for the Challenges of the 21st Century, supra note 113, at 280,285.

135 Given the benefits of specialization it is hardly surprising—and may even do some good—that economists tend to approach these questions by putting economics front and center. For a more extended discussion, see MARMOR, supra note 4, at 185-91.

136 See Marmor, supra note 112, at 28-30.

137 See Jacobs & Shapiro, supra note 125, at 1021; see generally Lawrence R. Jacobs & Robert Y. Shapiro, Politicians Don't Pander: Political Manipulations and the Loss of Democratic Responsiveness (2000) (arguing that politicians often produce—rather than respond to—public opinion, strategically manipulating polls and question wording to, in effect, create mass “preferences” consistent with their policy objectives).

138 See Oberlander, supra note 79.

139 See id.

140 One experienced public opinion analyst characterizes the available evidence on the public's support for vouchers this way:

Bowman, supra note 113, at 285.

141 See Peterson, supra note 93, at 201-19.

142 See generally Marmor & Oberlander, supra note 75 (providing a fuller discussion of the many reasons not to support voucher plans); see also Aaron & Reischauer, supra note 65; Butler, supra note 89 (providing responses to Marmor and Oberlander's arguments and a defense of vouchers).

143 See Aaron & Reischauer, supra note 101, at 8.

144 See MARMOR, supra note 43, at 216-18.

145 See Aaron & Reischauer, supra note 101, at 10.

146 Id. at 8.

147 See Robin Toner, Health Care Autopsy: Plenty of Targets to Blame for Failure, Phoenix Gazette, Sept. 27, 1994, at Al.

148 See Robin Toner, The Hard Lessons of Health Reform, N. Y. Times, July 4, 1999, at § 4, 1.

149 S. 1256, 105th Cong. (1999).

150 See Sean Wilentz, For Voters, the 60's Never Died, N.Y. Times, Nov. 16, 1999, at A27.

151 See generally John W. Kingdon, Agendas, Alternatives, and Public Policies (1984) (discussing how political agendas depend on a confluence of problem recognition, policy solutions and political conditions); Frank R. Baumgartner & Bryan D. Jones, Agendas and Instability in American Politics (1993) (proposing a punctuated equilibrium model of policy change, tracing the history of policy change in 20th century America, and analyzing the long-term changes in the structures and context of American political institutions).

152 See Baumgartner & Jones, supra note 151, at 57.

153 See generally Theodore R. Marmor, Forecasting American Health Care: How We Got Here and Where We Might be Going, 23 J. Health Pol., Pol'y & L. 551 (1998) (providing a more extensive discussion of the dangers of forecasting).

154 See MARMOR, supra note 43, at 136-38.

155 See Figure 2, infra at 253; Henry J. Aaron, Thinking About Aging: What We Know, What We Can't Know, and Why It Matters (Feb. 15, 1999) (unpublished manuscript, on file with author).

156 For similar points about the consequences of Medicare's complex environment, see Jerome P. Kassirer, Managing Managed Care's Tarnished Image, 337 New Eng. J. Med. 338-39 (1997), and Aaron, supra note 155.

157 Aaron, supra note 155, at 16; see also id. at 20-21.

158 For a similar point about the misuse of long-range projections, see id. at 7-10, 15-17.

159 See MARMOR, supra note 4, at 189-91.

160 See MOON, supra note 63, at 19.

161 See Marilyn Moon, Beneath the Averages: An Analysis of Medicare and Private Expenditures (visited Mar. 13, 2000) <http://www.kff.org/content/1999/1505/Moonbeneath.pdf>.

162 See MOON, supra note 63, at 19.

163 Doubts about policymakers mustering the political will required to impose fiscal discipline on the program through marginal adjustments stand curiously at odds with radical reformers' strong faith in these same policymakers' willingness to summon the political courage to make fundamental changes to the program's design.

164 See Remarks on Returning without Approval to the House of Representatives the “Taxpayer Refund and Relief Act of 1999,” 35 Weekly Comp. Pres. Doc. 1793 (Sept. 23, 1999).

165 See President Touts Successes in Remarks to LR Chamber, ARK. Democrat-Gazette, Dec. 12,atA21.

166 There is an irony to this development. The same social-insurance financing of hospital services that was so critical to gaining political support for Medicare in the first place has, through its artifact, the trust fund, become one of its greatest political vulnerabilities and the nominal foundation to support the attacks of the program's harshest critics. See generally MARMOR, supra note 4 (describing further the ironies of the political evolution of Medicare's trust fund); see also Oberlander, supra note 79. But see Eric Patashnik & Julian Zelizer, Paying for Medicare: Benefits, Budgets, and Wilbur Mills's Policy Legacy (1999) (unpublished manuscript, on file with author) (disputing the view that this development is an ironic legacy of the trust fund device). Patashnik and Zelizer argue instead that fiscal conservatives understood the implications of the trust fund mechanism from inception, and its ability to impose discipline on Medicare's budget was crucial to their willingness to support the program. See id.

167 Another analogy is useful here. When the U.S. declares war, no one shouts that the Department of Defense is going to run out of money. There is, of course, debate over the wisdom of the military engagement and disputes over the willingness of Congress to pay for the additional war-related expenses. However, no one would contend that the increased expenses due to a new military engagement will 'cause' the Department of Defense to become bankrupt.

168 See Eric M. Patashnik, Putting Trust in the Federal Budget: Trust Funds, Taxes, and the Evolution of Policy Inheritances (forthcoming 2000).

169 See. e.g.. Murray Edelman, The Symbolic Uses of Politics (1964) (exploring the symbolic processes underlying political claims); Charles Elder & Roger Cobb, the Political Uses of Symbols (1983) (examining the importance of symbols as a basis for political activity); Gary J. McKissick, Defining Choices: Interest Group Lobbying and the Framing of Policy Alternatives (2000) (unpublished manuscript, on file with author).

170 The oddity of worrying about a Medicare bankruptcy is also apparent when one considers the different political responses to the funding shortfalls for Medicare's hospitalization coverage (Part A), on the one hand, and the shortfalls for its coverage for physician services (Part B), on the other. Hospitalization insurance alone is financed by payroll taxes earmarked for Medicare's Part A trust fund. This is a mechanism designed explicitly to echo the same social-insurance principles as Social Security pensions. In contrast, when physician services were tacked on as Part B of the 1965 Medicare bill, physician expenses were to be financed by premium payments from current beneficiaries and by general federal tax revenues. Because general tax revenues can only run short, but not out, projected shortfalls in paying for physician services have simply been covered by additional general revenues, by increased premiums, or by cutbacks in expenditures. As a consequence, there have never been Medicare-Part-B crises of the form associated with Part A. It is only the projected shortfalls in the hospital trust fund that have triggered the recurrent crises over Medicare and the use of bankruptcy language. Thus, the experience with the trust fund demonstrates how important the funding mechanisms can be for the politics of a program. In that sense, the use of a trust fund is more than an accounting term of art. It has very real political implications and consequences. See Oberlander, supra note 79, for a cogent discussion of the different “crisis” politics of Medicare's component parts, and Patashnik supra note 168, for an insightful analysis of the politics of government trust funds.

171 What should one expect from those expert on the details of Medicare's programmatic operation who commit the conceptually distinct sin of leaving out political analysis altogether? For this sin of omission, the answer is this: a clear acknowledgement of the limitations of such assessments for the purposes of either predicting Medicare's future or prescribing reforms at any particular time. Such work makes a valuable contribution in providing such careful attention to the programmatic details of Medicare's history. Nevertheless, the caution about limits remains.