TM: It’s too easily a caricature for socialized medicine even though Medicare itself is a popular program. It’s a paradox. To ideological critics, it also represents a tax increase. But ironically, the financial meltdown and the expansion of the government’s role in financial regulation might actually provide an opportunity to open up the discussion in two strategic ways: expanding Medicare incrementally to those between ages fifty-five and sixty-five and adding newly disenfranchised retirees like the auto workers who will lose their health coverage at the end of the year. The second would be a dramatic, one-time chance to expand it to everyone and save the difference in administrative costs between Medicare, which runs about 3 percent, and private coverage, which runs about 13 percent. That is the dirty little secret of Medicare-for-all’s financial advantage.

TL: Is health information technology the new savior for controlling costs, as many have suggested?

TM: It’s an example of wishful thinking on the part of virtuous activists who are mismatched with the problem of cost control. No other industrialized democracy has hit a cost control home run with information technology, and it’s provincial of us to think so. Health information technology may or may not be helpful in other areas like improving care, but it’s not helpful in this one. And it might cost a fortune and become a boondoggle.

TL: What is necessary to control costs?

TM: To control the costs of medical care, you have to constrain the price of medical services, the number of those services, or a combination. The average price of medical services times the volume of those services equals the total of national medical expenditures. That tells you cost control must be controversial. The reason we don’t talk about it is because there will be losers. Cost control requires that there will be financial losers.

TL: What will it take to change the terms of today’s health care conversation?

TM: In my judgment, it would take the president of the United States to lead a fundamental re-examination of the presently limited debate over health care reform.

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