“Don’t touch Social Security or Medicare!” Every politician has been told that. They call them “the third rail of politics” because to touch them is the same as touching the third rail of a railroad track – it’s fatal. But both entitlement programs are destined for bankruptcy unless someone has the courage to change them.

President Biden and former President Trump are the leading candidates for the 2024 presidential election. Both have promised the voters they won’t touch Social Security or Medicare. Both are political cowards who don’t have the courage to change them and who aren’t willing to tell the American people the truth.

That’s not just my opinion; it’s also shared by healthcare economist John C. Goodman, writing for Forbes and for independent.org. Goodman says they’re both being irresponsible. According to the latest Social Security and Medicare Trustees reports, in the very near future the trust funds supporting these two programs will be depleted. If the president and the Congress do nothing in the interim, the law requires automatic cuts in benefits. Maybe they both just want that to happen so they don’t get the blame for making any changes.

But real leaders see problems that need solutions and make those solutions happen before the disaster happens. Goodman says, “In just eight years, nearly 78 million Medicare beneficiaries will face an automatic 11 percent payment cut in their hospital insurance benefits, and these cuts could come even sooner and strike even deeper if America is hit by a recession. In just ten years, 66 million Social Security beneficiaries will see their monthly benefit checks cut by 23 percent.”

But it gets worse. That is just the short-term problem. Looking further into the future, the Trustees reports remind us that we have made promises to millions of workers who are paying payroll taxes today, and the future cost of those promises far exceeds the expected revenues dedicated to support them. Further, the gap between future promises and future revenues keeps getting larger through time. Looking indefinitely into the future, the trustees tell us that the combined promises in both programs exceed expected revenues by $163 trillion.

It’s nearly impossible to get your head around a number like $163 trillion! That number is in current dollars and it is an unfunded liability that is almost seven times the size of today’s entire economy. Goodman says in a sound retirement system, we would have $163 trillion in the bank earning interest—so the funds would be there to pay the bills as they arise. In fact, we have no money in the bank for future expenses and there is no serious proposal to change that.

Hoover Institution economist David Henderson argues that of the two programs, Medicare is the easiest to reform. The reason? Social Security benefits come in the form of cash. Medicare benefits are services in kind. In making his argument, Henderson points to a well-regarded academic finding that Medicaid beneficiaries value enrollment in Medicaid at as little as 20 cents on the dollar. That means that if you offered the enrollees membership in Medicaid or a sum of money equal to a little more than one-fifth of the cost of Medicaid, a great many enrollees would take the money.

Is it possible that the value seniors place on Medicare is similarly much below what Medicare actually costs? If so, there would be an opportunity to spend less on medical benefits, give seniors a cash rebate and lower the taxpayers’ burden—all at the same time. A mechanism for accomplishing that would be a Health Savings Account, a device that allows younger people to make choices between medical care and other uses of money. A similar account, but with after-tax deposits and tax-free withdrawals (like a Roth IRA) for seniors would avoid the charge that the deposits are a tax dodge. But it would allow seniors to conveniently avoid unneeded care and bank the savings for other purposes.

This is one of a number of ideas proposed in Moderning Medicare, a multi-authored Johns Hopkins University publication, edited by Heritage Foundation scholar Robert Moffitt and former Heritage vice president Marie Fishpaw.

A number of authors point to the Medicare Advantage program, which already enrolls half of all beneficiaries, as the vehicle for change. In this program, seniors enroll in private plans that are similar to the employer-provided plans they had when they were in the work force. Medicare pays for a large share of the cost of the premiums.

American Enterprise Institute economist Joe Antos points out that in the Medicare Advantage program, seniors pay one premium to one plan. By contrast, in traditional Medicare they pay three premiums to three plans: one to Medicare Part B, one to Medicare Part D, and one for Medicap coverage. Antos says traditional Medicare must become more like Medicare Advantage, which saves seniors money and which allows for integrated care—such as combining medical costs and drug costs in the same plan.

In another chapter, former Medicare and Medicaid director Gail Wilensky and Johns Hopkins University School of Medicine professor Brian J. Miller argue that Medicare Advantage should be the default option for enrolling seniors. Right now, if seniors don’t elect a choice, they are automatically enrolled in traditional Medicare. Wilensky and Miller would enroll them in an MA plan instead. This idea has real merit.

In a chapter by Goodman, he argues for a number of reforms to make Medicare Advantage work better—including continuous open enrollment and the right of return to traditional Medicare. If the enrollees’ medical conditions change, they should be able to switch to a plan more appropriate for their care. If diabetes emerges, enrollees should be able to switch to a special needs plan specializing in diabetic care. If enrollees develop heart disease, they should be able to switch to a special needs plan for congestive heart failure. No one should have to wait 12 months to enroll in the plan that best meets their medical needs.

Currently, if a senior stays in an MA plan for more than a year and then choses to return to traditional Medicare there can be financial penalties. In all states, Medigap insurers are barred from discrimination on the basis of a health condition when the enrollee first becomes eligible for coverage. But a returnee from an MA plan can be “underwritten” and charged a higher premium if a health condition suggests higher medical costs. This is wrong, and it is easy to correct. Further, if people know that they can easily return to traditional Medicare when a need arises, that makes enrollment in MA plans more desirable.

(Author’s Note: For more on this issue, see my recent two-part series called Medicare Mistakes to Avoid.)

If you’ve done any traveling lately, like I have, you’ve probably spent a lot of time in airports. If you look around an airport, you’re struck by an undeniable fact – many Americans are obese. What can be done about this?

Grace-Marie Turner, writing for Galen.org, says obesity is a serious health problem for millions of Americans. In fact, about 42% of Americans are living with obesity. The association with other chronic conditions including heart disease, Type 2 diabetes, and stroke is incontrovertible.

Obesity also has been identified as one of the greatest risk factors for severe COVID-19 infection and death, and its burden does not fall equally on all communities. It is a particularly significant concern for communities of color. A newer generation of innovative anti-obesity medications (AOMs) is emerging that can provide another treatment option for those living with obesity.  But not all health plans cover these drugs, and under current law, few seniors have access to them through Medicare.

Medicare doesn’t currently pay for many of these drugs in an effort to save money. Medicare already is going broke, but its bankruptcy will be accelerated if it continues to pay for care only to treat diseases instead of allowing a broader range of treatment options to help get and keep people healthy. Both political parties stress their commitment to Medicare, and it is important to identify ways to improve the health of the Medicare population to reduce overall medical costs. Covering AOMs would be an important step in that direction.

When former President George W. Bush promoted creation of the Medicare drug benefit in 2003, he argued Medicare needed to be reformed “because it did not provide prescription drug coverage.” “Medicare would pay for a surgery, say, like ulcer surgery, for $28,000,” he said, “but wouldn’t pay $500 for the prescription drugs that would have prevented the ulcer in the first place.” Mr. Bush argued that “medicine had changed with the advent of prescription drugs, but Medicare hadn’t.”

This was a step forward to getting badly needed prescription drugs into the hands of seniors who needed them most. But not all drugs were eligible. The Medicare Modernization Act (MMA) passed in 2003, and the Medicare Prescription Drug Benefit (Part D) program it created began covering seniors in 2006. But the legislation banned coverage for medicines or classes of medicines “when used for anorexia, weight loss, or weight gain.”  And the ban still stands. And the results speak for themselves – just look around the airport!

In a classic example of Medicare policy gone awry, today Medicare will pay for expensive bariatric surgery – the last-resort of treatment for the morbidly obese – as well as treatments for more than 200 comorbidities linked to obesity such as certain cancers, dementia, and Alzheimer’s disease, but not for new treatments that scientists have developed that can address the disease itself. Only the government could come up with such utterly ridiculous healthcare policy.

This policy is costing American lives and money. A study by Harvard University researchers found that annual medical costs for adults living with obesity were $1,861 higher than medical costs for people of healthy weight and $11,481 higher for people with severe obesity. A study by Brookings Institution scholars found that people living with obesity have nearly 36% higher average annual health costs compared to healthy-weight individuals.

An unlikely alliance of groups is coming together to urge Congress to allow coverage of anti-obesity medications in Medicare. “It’s not every day that the pharmaceutical industry, the NAACP, a cancer center, and a nonpartisan think tank are all lobbying to achieve the same policy goal,” an article in STAT reads. “But an effort to expand Medicare coverage for obesity drugs has managed to unite them all, and many more groups across the health care industry, too.”

It’s time America woke up to the alarming obesity problem in our population. The problem threatens the lives of many Americans, the healthcare budget of the nation, not to mention the availability of many of our youth for military service. There is some indication, however, that Americans are aware of the problem. They rated obesity as the second greatest threat to public health, after opioids and fentanyl in a recent Axios-Ipsos American Health Index survey.

Turner summarizes, “Prevention saves money and lives. As the obesity problem grows, patients should be able to choose for themselves, in consultation with their physicians, from a full range of treatment options, including innovative anti-obesity medications.”

That would be a healthcare policy that actually makes sense!