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Credit: Huffington Post

Earlier this year, 235 GOP House members and 40 Republican Senators voted for the Paul Ryan budget and its plan to ration Medicare. By ending the traditional government insurance program and leaving the elderly with under-funded vouchers to purchase much more expensive coverage from private insurers, Ryan's Republicans would dramatically shift the cost burden to America's seniors. It's no wonder that the incredibly unpopular scheme put Medicare at the center of the 2012 election for Democrats and President Obama.

But now Oregon Democratic Senator Ron Wyden is putting that all at risk. Combing bad politics with even worse public policy, Wyden has joined with Congressman Ryan to propose a "bipartisan" plan to convert Medicare into a premium support plan in which the traditionally lower-cost system is just one option in a menu with private insurers. The result doesn't merely threaten to undermine Medicare as we know it. With one stroke, Ron Wyden essentially endorsed Mitt Romney's Medicare plan and with it, is helping to get vulnerable Republicans off the hook.

The Ryan-Wyden proposal, or "Ryden" plan, if you will, looks a lot like the Medicare prescription from last year's Domenici/Rivlin blueprint. Unlike Ryan's previous attempt to end Medicare as we know, Ryden maintains traditional fee-for-service government insurance as one option. As the New York Times explained:

Congress would establish an insurance exchange for Medicare beneficiaries. Private plans would compete with the traditional Medicare program and would have to provide benefits of the same or greater value. The federal contribution in each region would be based on the cost of the second-cheapest option, whether that was a private plan or traditional Medicare.

In addition, the growth of Medicare would be capped. In general, spending would not be allowed to increase more than the growth of the economy, plus one percentage point -- a slower rate of increase than Medicare has historically experienced.

Which is just one reason why Democrats hate the new Wyden initiative. Rep. Jim McDermott (D-WA) told Bloomberg News, I don't know why Ron Wyden is giving cover" to Ryan. " "For starters, this is bad policy and a complete political loser," one Democratic aide said. "On top of the terrible politics, they even admit that it dismantles Medicare but achieves no budgetary savings while doing so -- the worst of all worlds." The Obama White House, too, is worried:

"We are concerned that Wyden-Ryan, like Congressman Ryan's earlier proposal, would undermine, rather than strengthen, Medicare," said White House Communications Director Dan Pfeiffer. "The Wyden-Ryan scheme could, over time, cause the traditional Medicare program to "wither on the vine" because it would raise premiums, forcing many seniors to leave traditional Medicare and join private plans. And it would shift costs from the government to seniors. At the end of the day, this plan would end Medicare as we know it for millions of seniors. Wyden-Ryan is the wrong way to reform Medicare."

Republicans, on the other hand, are overjoyed. The reliably Republican Wall Street Journal calls it a "breakthrough." Current GOP presidential frontrunner Newt Gingrich, who in the 1990's famously declared he wanted to see Medicare "wither on the vine," described the proposal as a "very important breakthrough." As for his rival Mitt Romney, the Washington Times rightly noted that "Romney's plan is virtually identically to what Wyden and Ryan outlined today."

And that's not a good thing for the millions of Americans counting on Medicare to provide their health insurance in the future.

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Credit: CBO

He called for rationing Medicare, replacing it with an underfunded voucher system that would dramatically shift costs to elderly Americans. He proposed repealing the Affordable Care Act, slashing Medicaid by $1.4 trillion over the next decade and turning what's left over to the states as block grants. By 2021, his budget would leave up to 44 million more Americans without health insurance. His budget, one which garnered the votes of 235 House Republicans and 40 GOP Senators, would in turn use the savings to deliver $4.2 trillion in tax cuts, most of them to the richest Americans who need them least.

He is Wisconsin Representative Paul Ryan. And he is Politico's Health Care Policymaker of the Year.

As Politico revealed Tuesday, decimating the U.S. health care system and gutting the American social safety net apparently deserves praise, not scorn. For Politico, the catastrophic impact of Paul Ryan's draconian and dishonest budget matters far less than the fact that people are talking about it:

When House Budget Committee Chairman Paul Ryan released his budget plan in April, the Wisconsin Republican instantly changed the conversation about health care in America. It wasn't always a polite conversation. And it gave way to new Democratic charges that Republicans want to "end Medicare."

But Ryan got everyone talking about ways to get health care entitlements under control -- and he gave Republicans the most detailed illustration to date of how market forces could be used to do that. He has influenced how Republican presidential candidates such as Mitt Romney talk about health care, as they use variations of his Medicare plan in their campaigns. And if Republicans gain power after the 2012 elections, his blueprint is sure to be the starting point for their future health care policies.

As it turns out, Ryan didn't "instantly" change the conversation. Most Republicans, including his party's leadership, refused to endorse his 2010 Roadmap for America's Future until after the November mid-terms were safely won. And Ryan's goal to "end Medicare" is only the beginning of the unraveling of the safety net he would undertake.

To be sure, Ryan's voucher scheme would end Medicare as we know it. As Ezra Klein, Matthew Yglesias and TPM (among others) noted, Ryan's Republican deficit reduction gambit would inevitably lead to the rationing of Medicare.

Because the value of Ryan's vouchers fails to keep up with the out-of-control rise in premiums in the private health insurance market, America's elderly would be forced to pay more out of pocket or accept less coverage. The Washington Post's Klein described the inexorable Republican rationing of Medicare which would then ensue:

The proposal would shift risk from the federal government to seniors themselves. The money seniors would get to buy their own policies would grow more slowly than their health-care costs, and more slowly than their expected Medicare benefits, which means that they'd need to either cut back on how comprehensive their insurance is or how much health-care they purchase. Exacerbating the situation -- and this is important -- Medicare currently pays providers less and works more efficiently than private insurers, so seniors trying to purchase a plan equivalent to Medicare would pay more for it on the private market.

It's hard, given the constraints of our current debate, to call something "rationing" without being accused of slurring it. But this is rationing, and that's not a slur. This is the government capping its payments and moderating their growth in such a way that many seniors will not get the care they need.

Last year, Ryan acknowledged as much.

"Rationing happens today! The question is who will do it? The government? Or you, your doctor and your family?"

Of course, Ryan left out the real culprit - the private insurance market. But with 50 million uninsured, another 25 million underinsured, one in five American postponing needed care and medical costs driving over 60 percent of personal bankruptcies, Congressman Ryan is surely right that "rationing happens today."

As Paul Krugman explained using the chart above:

Medicare actually does a better job of controlling costs than private insurers -- not remotely good enough, but better...

If Medicare costs had risen as fast as private insurance premiums, it would cost around 40 percent more than it does. If private insurers had done as well as Medicare at controlling costs, insurance would be a lot cheaper.

But you don't have to take Paul Krugman's or Ezra Klein's word for it that "the GOP outsources Medicare to private insurers and gives senior citizens checks that cover less and less of the cost of insurance every year." In words and pictures, the nonpartisan Congressional Budget Office issued the same dire warning (see chart at top).

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That didn't take long. As the battle over health care reform reached a fever pitch in the fall of 2009, the Republican National Committee rolled out a "Seniors' Bill of Rights." But with the midterms safely won, the GOP has predictably turned its back on its pledge of "no cuts to Medicare to pay for another program." After all, the House GOP budget passed last week not only and massively shifts costs onto the elderly. As it turns out, the Ryan plan calls for the very same cuts to the Medicare Advantage program Republicans decried during the 2010 elections.

In November, the GOP rode a gray wave to victory, winning elderly voters by a 21 point margin. Key to the Republican triumph was the strategy of terrifying seniors about "death panels" and warnings about Democrats' slashing $500 billion from the insurance program covering 46 million elderly Americans. Despite the fact that the Affordable Care Act did not impact Medicare's core benefits and affected only the 15% of beneficiaries who enroll in higher cost private plans, Republicans ran devastating ads darkly warning of Armageddon. As the Wall Street Journal described one ad:

"Maybe Schauer's trying to hide his own vote to cut $500 billion from Medicare," said one typical television ad, this one targeting then-Rep. Mark Schauer (D., Mich.), who lost his re-election bid. "Let's save Medicare, and cut Schauer." Like others, this ad was paid for by the National Republican Congressional Committee.

But it was RNC chairman Michael Steele who put the GOP on record against Medicare cuts in the fall of 2009 with his "Seniors' Health Care Bill of Rights." Starring in his own ad, Steele proclaimed:

"Let's agree in both parties that Congress should only consider health reform proposals that protect senior citizens. For starters, no cuts to Medicare to pay for another program. Zero."

Steele's spot followed on the heels of his August 24, 2009 Washington Post op-ed similarly dedicated to producing fear and loathing among the elderly. Despite the conclusions of Politifact and the AARP that the Obama White House was not calling for benefit cuts to the basic Medicare program, Steele again portrayed the President as the grim reaper:

The Republican Party's contract with seniors includes tenets that Americans, regardless of political party, should support. First, we need to protect Medicare and not cut it in the name of "health-insurance reform." As the president frequently, and correctly, points out, Medicare will go deep into the red in less than a decade. But he and congressional Democrats are planning to raid, not aid, Medicare by cutting $500 billion from the program to fund his health-care experiment.

Steele's Bill of Rights for seniors quickly led to one of the most bizarre chapters in the midterm campaign. GOP leaders in both houses of Congress were furious with Steele and for good reason. The party that tried to kill Medicare in the 1960's and gut it in the 1990's had no intention of protecting it from the budgetary ax as soon as the campaign was over. As Politico reported at the time:

The congressional leaders were particularly miffed that Steele had in late August unveiled a seniors' "health care bill of rights" without consulting with them. The statement of health care principles, outlined in a Washington Post op-ed, began with a robust defense of Medicare that puzzled some in a party not known for its attachment to entitlements...

Steele was taken aback by the comments from Boehner, Senate Minority Leader Mitch McConnell (R-Ky.), Senate Minority Whip Jon Kyl (R-Ariz.), Senate GOP conference Chairman Lamar Alexander of Tennessee and Senate GOP policy Chairman John Thune of South Dakota and grew defensive during the 10-minute discussion, according to two people in the room.

Of course, Politico's description of the GOP as "a party not known for its attachment to entitlements" is a comical understatement when it comes to the perpetual Republican war on Medicare.

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Terrified by bogus Republican claims of draconian Democratic cuts to Medicare, elderly voters propelled the GOP to an overwhelming victory last November. Voters 65 and over, the only age group to support John McCain in 2008, boosted their share of the turnout to 21% from 16% two years earlier. Nationwide, Republicans won seniors by a staggering 59% to 38%. But now safely in power, Republicans are betraying the same elderly Americans who put them there. In the House, GOP leaders are putting Medicare and Social Security on the chopping block. And in the Senate, Minority Leader Mitch McConnell is threatening to shut down the government if they are not.

And that's just the beginning of the GOP's "gut and privatize" betrayal of the elderly. Call it the Great Republican Double-Cross.

On Friday, Minority Leader McConnell issued just the latest Republican threat to shut down the federal government if GOP demands aren't met. As the AP reported, McConnell's price for raising the debt ceiling (which his party did seven times under President Bush) is taking the axe to Medicare and Social Security now:

Senate Republican Leader Mitch McConnell warned on Friday that GOP senators will not vote to increase the government's borrowing limit unless President Barack Obama agrees to rein in Social Security, Medicare and Medicaid, laying down a high-stakes marker just weeks before the debt ceiling is reached.

House Minority Whip Eric Cantor (R-VA) has his eyes the retirement and health care programs for the elderly as well. Despite decrying the supposed "huge cuts in Medicare" Cantor claimed in December 2009 were part of the Affordable Care Act, declared this week that "It is very difficult to balance the budget within 10 years without cutting seniors' benefits now." And as House Budget Committee Chairman Paul Ryan told the AP this week, for fiscal year 2012 House Republicans will propose major changes to Social Security as well as the Medicaid and Medicare programs that provides health insurance for 100 million Americans. While withholding specifics, Ryan declared:

"What I'm going to put forward is a serious and honest attempt to fix this country's fiscal problems."

And as his Roadmap for America's Future shows, Paul Ryan is serious if not quite so honest about privatizing Social Security and rationing Medicare.

As TPM summarized the "slash and privatize" agenda in Ryan's Roadmap for America's Future:

Rep. Paul Ryan, (R-WI) the ranking Republican on the budget committee, recently detailed the Republican plan for Social Security that preserves the existing program for those 55 or older. For younger people the plan "offers the option of investing over one-third of their current Social Security taxes into personal retirement accounts, similar to the Thrift Savings Plan available to federal employees."

To that replay of George W. Bush's wildly unpopular privatization plan, Ryan's Roadmap adds the incredibly popular Medicare program now serving 43 million American seniors.

In 2009, 137 House Republican voted for an "alternative budget" drafted by Ryan which called for "called for "replacing the traditional Medicare program with subsidies to help retirees enroll in private health care plans." In a Washington Post op-ed last year (oxymoronically titled "A Roadmap to Saving Medicare"), Congressman Ryan explained how his voucher scheme would work:

Future Medicare beneficiaries would receive a payment to apply to a list of Medicare-certified coverage options. The Medicare payment would grow every year, with additional support for those who have low incomes and higher health costs, and less government support for high-income beneficiaries. The most vulnerable seniors would also receive supplemental Medicaid coverage and continue to be eligible for Medicaid's long-term care benefit.

Sadly for the party which cried "death panels," Ryan proposal would necessarily lead to rationing. As it turns out, Paul Ryan admitted as much.

When Ryan unveiled his Roadmap, as Ezra Klein, Matthew Yglesias and TPM all noted, privatization of Medicare was the centerpiece of his deficit reduction vision. But because the value of Ryan's vouchers fails to keep up with the out-of-control rise in premiums in the private health insurance market, America's elderly would be forced to pay more out of pocket or accept less coverage. The Washington Post's Klein described the inexorable Republican rationing of Medicare which would then ensue:

The proposal would shift risk from the federal government to seniors themselves. The money seniors would get to buy their own policies would grow more slowly than their health-care costs, and more slowly than their expected Medicare benefits, which means that they'd need to either cut back on how comprehensive their insurance is or how much health-care they purchase. Exacerbating the situation -- and this is important -- Medicare currently pays providers less and works more efficiently than private insurers, so seniors trying to purchase a plan equivalent to Medicare would pay more for it on the private market.

It's hard, given the constraints of our current debate, to call something "rationing" without being accused of slurring it. But this is rationing, and that's not a slur. This is the government capping its payments and moderating their growth in such a way that many seniors will not get the care they need.

Ryan acknowledged as much. Sadly for the Republican brain trust, he failed to follow the GOP script that says only Democratic reforms lead to "health care denied, delayed and rationed."

"Rationing happens today! The question is who will do it? The government? Or you, your doctor and your family?"

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Fresh off her pronouncements on the Fed's "quantitative easing" and federal aid to the states, last week Sarah Palin added the deficit and Medicare to her Potemkin façade of policy expertise. A year after she first called for converting Medicare into a voucher program, Palin took to the pages of the Wall Street Journal to endorse Congressman Paul Ryan's "Roadmap for America." Which is more than a little ironic for the propagator of the "death panels" myth. As it turns out, Ryan's plan would inevitably lead to the rationing of the Medicare program on which 46 million American seniors now depend.

In her WSJ op-ed Friday, the half term governor offered her full support for Rep. Ryan (R-WI) scheme to privatize Social Security and Medicare:

Rep. Ryan proposes fundamental reform of Medicare for those under 55 by turning the current benefit into a voucher with which people can purchase their own care.

On Social Security, as with Medicare, the Roadmap honors our commitments to those who are already receiving benefits by guaranteeing all existing rights to people over the age of 55. Those below that age are offered a choice: They can remain in the traditional government-run system or direct a portion of their payroll taxes to personal accounts, owned by them, managed by the Social Security Administration and guaranteed by the federal government.

Hoping to lead the party that tried to block Medicare in the 1960's and gut it in the 1990's, Sarah Palin heartily endorsed Paul Ryan's proposal to cure what ails the health insurance system for millions of American seniors by killing it. In an August Washington Post op-ed ("A Roadmap to Saving Medicare") that mentioned neither the word "voucher" nor "privatization," Congressman Ryan intends to do apply both to address the long-term financial issues facing the system:

Future Medicare beneficiaries would receive a payment to apply to a list of Medicare-certified coverage options. The Medicare payment would grow every year, with additional support for those who have low incomes and higher health costs, and less government support for high-income beneficiaries. The most vulnerable seniors would also receive supplemental Medicaid coverage and continue to be eligible for Medicaid's long-term care benefit.

The only alternative, he insists, "is the European-style death spiral of the welfare state":

Kick the can down the road as our debt explodes. Under an ever-expansive, all-consuming central government, costs will be contained with Washington's heavy hand imposing price controls, slashing benefits and arbitrarily rationing seniors' care.

Of course, Paul Ryan is the only one proposing rationing Medicare. And, as it turns out, he has admitted as much.

When Ryan unveiled his Roadmap back in February, as Ezra Klein, Matthew Yglesias and TPM all noted, privatization of Medicare was the centerpiece. But because the value of Ryan's vouchers fails to keep up with the out-of-control rise in premiums in the private health insurance market, America's elderly would be forced to pay more out of pocket or accept less coverage. The Washington Post's Klein described the inexorable Republican rationing of Medicare which would then ensue:

The proposal would shift risk from the federal government to seniors themselves. The money seniors would get to buy their own policies would grow more slowly than their health-care costs, and more slowly than their expected Medicare benefits, which means that they'd need to either cut back on how comprehensive their insurance is or how much health-care they purchase. Exacerbating the situation -- and this is important -- Medicare currently pays providers less and works more efficiently than private insurers, so seniors trying to purchase a plan equivalent to Medicare would pay more for it on the private market.

It's hard, given the constraints of our current debate, to call something "rationing" without being accused of slurring it. But this is rationing, and that's not a slur. This is the government capping its payments and moderating their growth in such a way that many seniors will not get the care they need.

Ryan acknowledged as much. Sadly for the Republican brain trust, he failed to follow the script that only Democratic reforms lead to "health care denied, delayed and rationed."

"Rationing happens today! The question is who will do it? The government? Or you, your doctor and your family?"

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When it comes to the health care reform bill, perfect is the enemy of good. But Republicans are the enemy of everything. And on Sunday, every member of the House GOP will likely vote against the final health care reform bill that will bring coverage to 32 million more Americans, end insurance company abuses involving rescission, pre-existing conditions and lifetime caps on payments, all while slashing the federal budget deficit by $1.3 trillion over the next two decades.

But in saying no in that simple up-or-down vote scheduled for Sunday, Congressional Republicans are choosing to perpetuate the worsening symptoms of an American health care system already in critical condition.

Here, then, are the 10 Republican No's on health care:

1. No Hope for the 50 Million Uninsured
2. No Improvement for 25 Million More Underinsured
3. No Halt to the Rapid Deterioration of Employer-Based Coverage
4. No Help for the 1 in 5 Americans Already Postponing Their Medical Care
5. No Drop in the 62% of Bankruptcies Due to Medical Bills
6. No End to Double-Digit Increases in Business Insurance Premiums
7. No Barrier to Family Premiums Doubling in 10 Years
8. No Reduction of the Near-Monopoly Status in 94% of Insurance Markets
9. No Reversing the Dramatic Decline in Emergency Room Capacity
10. No Rescue for the 45,000 Uninsured Americans Needlessly Dying Each Year
11. No Chance for Failing Red State Health Care

The data and details behind each follows after the break.

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Among the most pernicious and blatantly false Republican talking points designed to obstruct health care reform is the fear-mongering claim that Democratic proposals will lead to "rationing." Of course, with almost 50 million uninsured and another 25 million underinsured, Mitch McConnell's dystopian future of a system which "denies, delays, or rations health care" is already today's nightmare for millions of Americans. But as it turns out, recent studies show that the market failure that is the crumbling U.S. health care system is producing a another, often hidden crisis: self-rationing.

As McClatchy reported last week, a new Consumers Union survey revealed that due to skyrocketing costs and reductions in coverage, Americans are forced to deny themselves needed medical treatment. Among the findings of CU's poll of a 1,002 respondents:

In the new poll 59 percent said that the cost of their health care had increased more than their other expenses over the past two years. Fifty-one percent said they had faced difficult health care choices in the past year. The most common responses were putting off a doctor visit because of cost (28 percent), not being unable to afford medical bills or medication (25 percent), and putting off a medical procedure because of cost (22 percent).

Twenty-eight percent said they had lost or experienced cutbacks in their health care coverage in the past year. The greatest concerns about health care expressed by respondents were a major financial loss or setback from medical cost due to an illness or accident (73 percent), not being able to afford health care in the future (73 percent), necessary care being denied or rationed by health insurance companies (73 percent), and the prospect of rising costs forcing them to choose between health care and other necessities (64 percent).

Those dismal results echoed the shocking revelations from an April 2009 Thomson Reuters survey.

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(Disclosure: I'm working with Brave New Films on their Sick For Profit campaign, exposing insurance industry practices. Check us out on Facebook.)

The New York Times published a very nice press release from the desk of Humana, one of the nation's largest health insurance companies. The reporter interviewed a bunch of employees at Humana, all of whom were horrified to see themselves depicted as "villains" in the health care debate. I agree with Yves Smith, this is an absurd angle for a story, an extreme example of selection bias. The people who work at Humana probably have a sense that their employer, um, pays their salary, and thusly, what's good for the employer is probably good for them. Similarly, most people hold a favorable opinion of themselves just as a matter of getting through the day. Not to mention the fact that their understanding of the functioning of Humana is limited to their job description. It is not possible to gain much of a perspective on the health care debate or industry practices by asking a midlevel manager "Do you think you're the worst person alive?"

Since when is it legitimate, much the less newsworthy, to get a company's perception on its embattled status, at least without introducing either some contrary opinion or better yet, facts, to counter the views of people who will inevitably see what they are doing as right? I hate to draw an extreme comparison to make the point, but staff in Nazi concentration camps also thought they were good people. It is well documented that for all save the depressed, people's assessments of their own behavior is biased in their favor.

There is some revelatory stuff in the article, however. David Sirota flags one employee saying that Humana believes in keeping down costs by "controlling utilization":

Now, I know we're supposed to think that private for-profit health care companies don't ration care, while government-run programs like Medicare do - but as the insurance industry admits right here for all to see, that's just not the case. The obvious truth is that the health insurance industry works hard to "control utilization" - that is, it works hard to make sure that when you need a costly medical service, you are "controlled" (read: prevented) from getting it.

Sure, we're all against excessive testing - and there are good ways to deal with those inefficiencies. But that's not what the insurance industry is talking about. It is talking about its practice of rationing care - and now that reality is right there in black and white for all to see.

The truth of the matter is that many of the charges that insurance companies like WellPoint level at the public option and regulatory changes sought in the health reform bill mirror accepted industry practices. WellPoint, which emailed its own customers yesterday attacking the Democratic plan, claimed that health reform will “increase the premiums of those with private coverage.” Yet WellPoint routinely hikes their own premium prices by close to double digits annually, leading to ever-increasing profits. The email stated that millions of Americans would lose their private coverage and be forced onto a government-run option if the Democratic bill passed (nothing could be further from the truth); yet WellPoint routinely uses the practice of rescission to drop their own customers from coverage if they ever try to use it, and they've admitted they would continue doing so unless forced to stop by law.

The email is an example of the astroturf practices from the industry, including, no doubt, pitching to the New York Times a story putting the human face on insurers. Many of these astroturf efforts spring from the same sources as the corporate lobby groups activating the tea party protests at town hall meetings throughout the country this August. They're trying to change the subject, away from facts, like how they're spending less of their premium revenue on medical care over the years, from 90% in the early 1990s to around 80% today. Or how they use rescission and pre-existing condition to make profits off cherry-picking the healthy and denying everyone else care. House and Senate leaders have requested more and more information about insurance company practices; Dennis Kucinich has joined that effort. But the insurance industry, while nominally siding with reform, wants to keep the focus on efforts against it, in service to de-fanging it.

Digby points out the obvious class system that's firmly in place for health care. There are so many exceptions, so much denial of care, we really should start calling it "KatrinaCare." (h/t DCBlogger)

Other countries have systems that prioritize health care treatment on the basis of need --- a triage system. We prioritize health care on the basis of who can pay. And in the most perverse form of rationing there is, we make the sickest people have the most difficult time getting access to health care. (The sickest, after all, can't hold down a job, so the employer based system doesn't really work for them, at least not in the long term.)

And let's not forget: If you get sick while you're on unemployment, they can stop your benefits because you're no longer ready to work!

The idea that the US doesn't ration health care is absurd. We certainly do. We just make people do it to themselves out of economic hardship. I guess that's supposed to be a tribute to our sense of individualism and personal freedom.

Hey, nobody's going to tell you you can't be treated --- you made that decision all by yourself when you opted not to have a lot of money. That's what freedom's all about. (Unless you're sick and you want to die, of course, in which case the state won't let you.)

The debate is really about irrational rationing vs rational rationing -- and the US is the undisputed leader of the first method. When we set our minds to it, nobody can be as irrational as we are.

This program is controversial because at some point, it probably will be used to influence care - and payment. Women's health activists warn that women respond differently to treatment than men, and surgeons look on it as an infringement on their medical judgment. (Even though their judgment is often demonstrably bad.)

But since the medical-industrial complex (and the wingnut media) is so firmly against it, how bad could it be?

WASHINGTON — The $787 billion economic stimulus bill approved by Congress will, for the first time, provide substantial amounts of money for the federal government to compare the effectiveness of different treatments for the same illness.

Under the legislation, researchers will receive $1.1 billion to compare drugs, medical devices, surgery and other ways of treating specific conditions. The bill creates a council of up to 15 federal employees to coordinate the research and to advise President Obama and Congress on how to spend the money.

The program responds to a growing concern that doctors have little or no solid evidence of the value of many treatments. Supporters of the research hope it will eventually save money by discouraging the use of costly, ineffective treatments.

The soaring cost of health care is widely seen as a problem for the economy. Spending on health care totaled $2.2 trillion, or 16 percent of the nation’s gross domestic product, in 2007, and the Congressional Budget Office estimates that, without any changes in federal law, it will rise to 25 percent of the G.D.P. in 2025.