Anyone with a fascination for the arcane could see one result this week from the nation’s Rube Goldberg health care system when a couple of conflicting ideas landed in the newspaper. Readers may well have sympathized with both stories, one of which concerns expanding Medicare and the other reflects on its limits. Both, however, strongly suggest a system in need of radical overhaul.

Rube Goldberg, of course, drew complex cartoons showing methods of maximum effort for minimal result. The redundant paperwork, extensive referral network, needless defensive testing and myriad overlapping sources of revenue (all reaching back to an overwhelmed citizenry) that comprise health care would make Mr. Goldberg weep in humility.

This isn’t a comment about the quality of care, but about the twists, turns and pirouettes required to get to that part of the system. It is also about what doctors receive once the care is administered, and from what an article last Sunday in The New York Times suggests, it is not enough. HMOs representing 2.2 million people in the last four years have either left Medicare or limited their participation because of low reimbursement rates. In addition, countless doctors, individually, have chosen not to accept new Medicare patients. Like Medicaid, the health care coverage for the poor, Medicare is driving doctors away because their costs noticeably exceed the government reimbursement rate in many areas.

That is happening all over the country and it is worse this time because private insurance is demanding a much leaner rate and is unwilling to pick up part of the public health-care bill, as it had in the past. The Congressional Budget Office estimates that the Bush administration has budgeted $300 billion less than needed for the next decade just to cover services currently offered. Doctors in the Times article cited a reimbursement cut this year by the administration as their reason for deciding not to take new Medicare patients.

The second story is about Sens. Olympia Snowe and Jay Rockefeller’s fight to expand Medicare to cover oral cancer drugs, funding the new coverage through savings elsewhere. Currently, Medicare covers injectable drugs or an oral version if it is identical to an injectable drug. That accounts for all but a small minority of treatments, but the senators make a strong case that future cancer drug treatment is more likely to be oral and that the federal system should encourage these advances. Sen. Snowe, long a champion of adding a broad prescription-drug benefit to Medicare, said of the cancer-drug proposal, “It’s clearly time for Medicare to catch up – or we risk condoning a de facto, two-tier system of health care delivery for cancer patients: one for those with the money to pay for superior treatment, the other for the rest of America.”

She’s absolutely right, but the two-tier system that is developing now is beginning to separate private-pay patients and those on the public system. The emerging pattern cannot, as a matter of fairness or as a practical way to treat the ill, continue for long. If Congress and the White House are not willing to spend tens of billions more for Medicare in the coming year – and the evidence is they are not – then the two alternatives are to overhaul the system or cut services (or watch them be cut, as is happening).

An overhaul, even in an election year, is preferable. If nothing else, it could remove some of the Goldberg machine and save further by limiting access where it will hurt least, rather than tolerating the ad hoc limits that are occurring now. An honest overhaul would also establish a baseline of care for those outside of Medicare, establishing what constitutes adequate minimal coverage. True, such a determination would contribute to the problem of a two-tier system, but it would be a better two tiers than the current Medicare choice of limited or nothing.