To preserve and strengthen Medicare.

Medicare, notwithstanding its limitations, has been widely recognized as our nation's most effective and most popular health insurance program1"4 It has been the mainstay of medical care for elderly Americans, like me, as well as for millions of nonelderly with disabilities. Many in the United States have viewed Medicare as a model, or even a foundation, for a program assuring health care to all,5 but under an ostensibly well-known, yet generally misunderstood law enacted in 2003, an elaborate process has been underway that, if not halted and reversed, will destroy Medicare under the pretense of saving it. The 1965 creation of the Medicare program advanced the nation's aspiration to end poverty and promote equality. Medicare was the nation's second social insurance program after the federal Old Age and Survivors Insurance Act ("Social Security"; 1935).6 By providing health care coverage to older Americans through a government-based program, Medicare greatly reduced the likelihood that major illness in old age could force a choice between medical impoverishment and early death. In 1972, Congress extended Medicare to people with disabilities and those with end stage renal disease. From its birth, Medicare had to contend with powerful foes. The medical profession viewed Medicare as a threat to its professional autonomy.7 The private insurance industry feared Medicare as the first wave of a social insurance surge that could destroy that industry. Others' opposition was rooted in ideology: to them, Medicare was an entering wedge for socialism. AMA advertising exploited these fears.8 Apprehensive doctors and hospitals were eventually won over by the advent of Medicare's steady, generous revenue stream. A broad political consensus developed, supporting Medicare as a government program. As the program's architects intended, its funding by a payroll tax-based trust fund gave people a sense of ownership and entitlement. Although, from the start, Medicare law included an opening for private health plans, very few insurers availed themselves. Then, between 1982 and 1997, 3 legislative reforms were adopted in efforts to inject commercial insurer competition into Medicare. These largely failed. The first sought to recruit beneficiaries into "managed care" models such as abounded in private health insurance, but Medicare beneficiaries shunned these as too restrictive. The later efforts focused on fee-for-service plans. These foundered when commercial insurers found competition with traditional Medicare unprofitable.9 Medicare's financing mechanism and its "trust fund" terminology were designed in part with a view to giving potential beneficiaries a sense of ownership and trust. The financing mechanism is, however, sensitive to economic, demographic, and medical practice variables. From time to time, its income and obligation trends have signaled a need for adjustment. That might involve tweaking the payroll tax, reimbursement rates, or benefits. The trust fund, in fact only an accounting mechanism to register the balance or imbalance between projections of revenues and obligations, has served to signal when adjustment might be in order. However, popular misunderstanding of this has enabled foes of Medicare to respond to occasional projections of future revenue shortfalls by prophesying Medicare's bankruptcy.10 As long as Medicare could count on a supportive political consensus, adjustments were made uneventfully. However, in 1994-95, with a Republican/Gingrich sweep of the