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Tough trade-offs will be the topic early next year when Congress takes up Medicare reform.

The nation's cornerstone health program for the elderly would normally be a taboo subject in an election year. But lawmakers have no choice.

Why? When a drug benefit was added to Medicare in 2003 without an increase in revenue, Congress placed in the law a provision for a reform process that would be triggered if the system's finances became dire enough.

For the second year in a row, Medicare's finances hit the trigger point.

That forces President Bush to present a reform plan shortly after delivering his annual budget in February. The law also demands that Congress start considering the reform measure within three weeks of receiving it.

That creates an opportunity for consumers to get involved in a national economic debate that will, in some way, affect us all.

What's wrong with Medicare? The program has an unfunded liability six times that of the Social Security system and is catapulting down an unsustainable spending path, said Thomas R. Saving, a Medicare trustee and senior fellow with the National Center for Policy Analysis, which just completed a study on the system's woes.

And the problems will get increasingly dire each year.

Unfortunately, solutions to the Medicare problem are neither clear nor easy. Here are a few that have been suggested to resolve at least a portion of the system's woes:

● Raise the entry age. When Social Security was threatened with insolvency in 1983, trustees made a simple fix. They gradually boosted the age at which recipients could collect full benefits from 65 to 67. Although Social Security is again on the ropes, that one change bought decades of solvency. And it made sense because people were living longer and were better able to work into their late 60s.

The same could be done for Medicare, said Dr. Robert Berenson, a senior fellow at the Urban Institute in Washington, D.C., but with one caveat: Because some people cannot work to age 67 and often cannot get coverage in the individual-health-insurance market when they have chronic conditions, workers should be given the ability to buy into Medicare, he said. The coverage might be costly, he added, but it at least would be available without a medical exam and would cover pre-existing ailments.

● End private plans. For the last 20 years, Medicare recipients have had the option of sticking with the fee-for-service Medicare program or handing their Medicare dollars to a private health-care company that promises to provide the same services as Medicare and then some.

Health-care providers contended that the private sector was more efficient, so they could provide more for less. But as it turns out, the private Medicare Advantage plans provide more for more, costing the Medicare system 12 percent to 15 percent more than government-run Medicare costs, said Maria Freese, director of government relations at the Committee to Preserve Social Security and Medicare, a Washington advocacy group. Eliminating Medicare Advantage plans, in which about 20 percent of Medicare recipients have enrolled, would give the system about two additional years of solvency.

The downside: The people in the privately run plans would lose extra services they may have come to expect.

● Cut waste. Like any bureaucracy, Medicare has its share of wasteful spending. How much is a matter of debate. Some say waste accounts for 30 cents of every dollar spent. Others say it's significantly less.

However, virtually all experts argue that some systemic changes are needed to cut wasteful health spending. Among other things, there is no formula for requiring "preapproval" for elective surgeries, even when medical research indicates that this preapproval would ensure better care, Berenson said. For instance, the system approved a procedure to treat macular degeneration, an eye ailment that can cause blindness. However, there are two types of the disease, and the procedure treats only the less common type. Berenson believes that many people receive an ineffective treatment because some doctors are willing to perform it even when the likelihood of success is extremely low and because Medicare has no ability to screen out those who are unlikely to benefit.

There are 20 or 30 similar problems, he added.

● Let patients drive. One of the problems with health spending — both in Medicare and private industry — is that consumers are impervious to the costs when somebody else is paying the tab, said Andrew J. Rettenmaier, executive associate director at the Private Enterprise Research Center at Texas A&M University in College Station. The presumption is that consumers would be more cautious about getting cost-effective treatment if they have economic incentives to do so. That's got some experts calling for "vouchers" that Medicare recipients could use or save.

There are a couple of catches. One is that it's difficult, if not impossible, to compare the cost and effectiveness of medical services because there are no published prices or statistics.

The other is the possibility that you could run out of vouchers.

● Raise taxes. Many experts believe that some boost in tax rates will be necessary. But if the entire cost is paid this way, the price would be huge, Rettenmaier said.

The National Center for Policy Analysis study found that we could get the system back in balance by boosting federal taxes — excluding the Medicare and Social Security payroll taxes — by 10 percent by 2020. Or we could nearly double the Medicare payroll tax to 5.4 percent in the same time frame.

● Raise premiums. A portion of Medicare costs are paid by premiums charged to recipients. Deducted from Social Security benefits, the premiums generally cover about 25 percent of the program's costs. Some believe recipients should pay a greater share. But if premium increases were the only tool used to get Medicare back in balance, they would have to more than quadruple to $509 a month by 2020, the study found. And again, the longer we wait, the bigger the required increase.

"I think the solution will be a mixture of modest new financing, perhaps some change in eligibility, and it would have to include an ability to manage costs in the program," Berenson said. "But no one has come out with the options because it involves choices — tough choices — and no one wants to acknowledge that."