Under Obama’s design for Medicare, Yglesias argues, the poor will also get “bare bones” coverage from Medicare, and richer seniors will buy supplemental policies to beef up their coverage. Iglesias doesn’t quite say why. Does he mean capping what the government spends will cause doctors to stop treating Medicare patients? Or is he arguing today’s benefits will be cut for tomorrow’s seniors?

Yglesias labels Ryan’s plan “outsourcing” to the private sector and Obama’s “central rationing.” At its core, his argument is about rationing—that thing most people believe America doesn’t do, but is the elephant in the room whenever public discussion turns to controlling medical costs. Yglesias argues:

Under either version, seniors will face the novel situation of potentially being denied useful medical treatment on the grounds that Medicare can’t afford to pay for it. Over the long term, something along those lines is likely inevitable.

That takes us into dangerous territory. As Don Berwick, the former Medicare administrator has argued for years, America needs to rationalize—not ration—the great quantities of healthcare services it consumes. We should pay only for what’s clinically effective at a reasonable price, Berwick preaches. In theory, that’s a simple idea; in practice it’s hard to implement without cries of rationing from politicians, technology sellers, and healthcare providers whose incomes are at stake.

At the end of his post Yglesias laments that we are “getting no real debate” over whether GDP+ 0.5 percent cap is the right number to curtail Medicare spending. He seems to be opening the door for a full throated discussion about this fundamental issue: Do we as a country want to want to continue unlimited spending on ineffective and expensive treatments? Or do we want to be more careful with the healthcare budget even if it means a senior may not get a treatment a doctor suggests might work or a seller of new, whiz-bang technology makes less profit?

That is his most important point. He needs to go further and lay out explicitly what’s at stake. So should other journalists.

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Trudy Lieberman is a fellow at the Center for Advancing Health and a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR’s healthcare desk, which is part of our United States Project on the coverage of politics and policy. Follow her on Twitter @Trudy_Lieberman.