The Washington Post asks a question that has such an obvious answer, Alec MacGillis takes a couple of dozen paragraphs to avoid answering it.  Who says no in a single-payer system?

The question came from a Colorado neurologist. “Mr. President,” he said at a recent forum, “what can you do to convince the American public that there actually are limits to what we can pay for with our American health-care system? And if there are going to be limits, who . . . is going to enforce the rules for a system like that?”

President Obama called it the “right question” — then failed to answer it. This was not surprising: The query is emerging as the ultimate challenge in reining in health-care costs that now consume $2.5 trillion per year, or 16 percent of the economy. How will tough decisions be made about what to spend money on? In a country where “rationing” is a dirty word, who will say no?

That’s easy: the payer says no.  The reason why most of us haven’t had liposuction or plastic surgery is because we have said, “No,” either for financial or common-sense reasons.  Health insurers say no now to a range of treatments, mostly either elective or experimental, in order to save costs.  When the government replaces insurers, they will say no — but they will also have closed the system so that no one can pay their own money and say yes for themselves.

Oh, it won’t sound like “no.”  How will the government say “no”?

Although Obama and his advisers have held up providers’ spending patterns as the crux of the crisis, proposals in Washington go only so far in addressing the thorniest questions about who gets what care. Instead, cost-saving measures are focused on introducing a public insurance option to compete with private insurers, or on general cuts in Medicare and Medicaid payments to hospitals.

The bills being written would put new emphasis on evaluating treatments according to their “comparative effectiveness,” or weighing the risks and benefits of different types of treatment for the same illness, but the bills stop short of incorporating cost-benefit analyses into the findings or of requiring that providers abide by conclusions.

Comparative effectiveness is a rationing system that weighs the costs of treatment against the relative value of the person getting treated.  The people most likely to be affected by “comparative effectiveness” rationing in a single-payer system are the elderly.  Stuart Altman explained that all too well to Congress earlier this year:

Remember, our population is aging. And with the very, very elderly, the costs go down, so that percentage should be falling, and it’s not. Second, the cost of care is growing by so much, so at the same percentage, it’s worth a lot more. So let’s go back to the issue of comparative effectiveness, which we’re supporting. That’s where that can have a big impact. It’s not only there, but that’s where the waste is. That’s where people are using technologies that really either don’t work at all or keep people alive for for very limited [time] and [at] very high cost.

Hospice is one option, but we do need take account of the cost — you know, I hate to say it, the cost-benefit of some of the things we do. And either we can do it directly, or we can do it by bundling the payments and let the delivery system deal with it. So it’s a combination of the delivery system dealing with it, or, and/or providing more information for people to make the right decisions, both for themselves and for the care.

Basically, the government will tell some people that they’re just not worth the effort to treat, and will send them to hospice to die instead.  And thanks to what will eventually be a nationalization of the health-care industry, just as in Canada and “England”, there won’t be any private options left, either.

Such a shift would probably be a shock to the system of many Americans, who have grown used to having any and all health-care options, regardless of cost, available to them.

Not if they start paying attention now.  If they do, they can stop ObamaCare in its tracks by calling their elected representatives and promising to replace them if they support this.  It’s really not rocket science at all.