>>As long as the items covered increase and the costs of providing them increase in unpredictable ways- at the same time that contributions are fixed- the notion that Medicare is a program whose surpluses/deficits can be predicted is absurd.

Actually it may well reduce cost, since a huge proportion of expenditure goes in the last month of life.

This is not an easy discussion. However, not everybody wants heroic measures and more than once I was with somebody who whispered that they were ready and in fact were looking forward to being with their wife or husband again. Yet systems and families are primed to believe that heroic postponement of death is a sign of love and quality. I know you say that's not your experience, but I saw it repeatedly and came to realize that the elderly patient who politely and insistently says she want to go home in heart failure knows exactly what she is doing,