When the experts in Washington, D.C., talk about Medicare reform these days, they are really talking about certain numbers, not about doctors, hospitals or patients.

The Medicare reform discussions and the divergent plans, whether they come from a liberal Democrat or a conservative Republican, share one thing in common: They all have the goal of making Medicare spending grow more slowly. 

This became clear Thursday, January 31, as a panel of experts discussed competing Medicare reform proposals at the annual conference of the National Academy of Social Insurance, a nonpartisan think tank dealing with Medicare and Social Security issues.

"Let's first set a budget target" is the way experts in Congress and think tanks all approach the problem, said Dr. Kavita Patel, a senior fellow at The Brookings Institution. Generally, that target is the gross domestic product (GDP) plus 1 percent. "We start with a GDP target and work backwards," she said.

All the current proposals recognize that there is a tremendous and constantly growing demand for medical care, as well as a growing stream of boomers coming onto the rolls. Even if we become more efficient, the millions of additional boomers entering Medicare will drive up spending substantially, Thus, the best we can hope to do is keep the growth rate in health care as close as possible to GDP. 

The great problem facing the United States is that health care is taking an ever-larger share of the federal budget and the national economy, squeezing out spending for other goods and services. Health spending soared to 17 percent of the GDP last year, and is expected to reach more than 22 percent by 2020. By contrast, most other industrial nations spend approximately 10 percent of their GDP on health care. GDP is the total value of all the goods and activities produced by a nation’s economy.

In recent decades, U.S. health spending has grown far faster than the economy. If the GDP grew 4 percent, for example, health outlays might rise 7 to 9 percent. Meanwhile, wages are growing much slower, leaving employers and workers with less money for salaries and wages as more is spent on health insurance. For the federal government, Medicare takes an ever-larger share of federal spending.

So the focus, at this time of big budget deficits, is deciding what the spending target should be, and for lawmakers to consider the various tools available to reach that target. This was the message of the expert panel discussion at the NASI conference.

This fixation on budget numbers and the deficit should not be overdone, warned Tricia Neuman, the panel’s moderator. Neuman is a senior vice president of the Henry J. Kaiser Family Foundation and director of its program on Medicare policy. While folks in Washington focus on the budget, she said, they should remember "people like this program. Experts may complain, but people who use the program are very grateful for it."

House Budget Chairman Paul Ryan (R-Wis.) and President Obama (through the Affordable Care Act) have the identical goal for slowing Medicare growth, seeking to limit it to GDP plus 1%. Their methods are drastically different. But their common hope is that increased health care spending is tolerable when it slows down to just slightly faster than the overall expansion of the economy. Health spending has sometimes grown at 3 or 4, or 5 or more percentage points faster than the  economy. 

Some of the competing ideas to get Medicare specifically, and health care in general, to grow more slowly include:

• New private plans to compete with Traditional Medicare. Someone who turns 65 and is eligible for Medicare could choose the traditional program, where the new beneficiary could select any doctor or hospital that accepts Medicare, or pick from a private plan with a fixed network of doctors and hospitals. The competition should hold down costs, advocates believe. This type of plan, called premium support, was advocated by GOP presidential candidate Mitt Romney during the 2012 campaign. Romney found that this is an unpopular idea. Jane Horvath, executive director of health policy at Merck & Co, backed this approach at the panel discussion on Thursday, although she said it might need to be renamed, jokingly calling it "the plan that shall not be named." Horvath's version would limit individual plans to metropolitan areas, a contrast with previous proposals for national plans. Thus, an expensive New York plan could not drive up costs in Iowa, she said.

• Another reform idea offered by Horvath would provide a bigger federal subsidy for dual eligibles, those who qualify for both Medicare and Medicaid. Dual eligibles would move into managed care plans, where coordinated care should make it less costly to provide care for this group of people, she said.

• Dr. Patel also discussed Accountable Care Organizations (ACOs) and how doctors, hospitals, nurses and social workers could coordinate care to follow patients after they leave the hospital, making sure they are following instructions for full recovery. The goal is to save money by reducing readmissions to hospitals. "Almost every shop in town is thinking through options," she said referring to the plethora of think tanks, foundations and other organizations housing experts from every political persuasion.

The details of all the plans, however, take second place during the deliberations in which the target for the rate of growth—the GDP plus 1 percent—is the obsession for all policymakers.

"We need to take $1 billion out of the program in 10 years," Horvath, said referring to efforts to keep Medicare outlays below the historical rates of growth.

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