As Maryanne Wood sits on the passenger side of the car, she reaches forward and closes the air conditioning vent.

"I can't have that cold air blowing on my face," she says. "It can trigger serious pain."

Maryanne suffers from trigeminal neuralgia, a condition that causes excruciating pain in the face. At one point it was quite common for people suffering from it to take their own lives, earning the condition the moniker of "suicide disease."

"Winter, with the cold air and cold wind, largely puts me out of commission," Maryanne says. "There are days where you are literally just trying to survive and battle through the pain."

As a result, she is now one of the roughly 9-to-10 million disabled people on Medicare. And for Maryanne, that means she can't get the treatment she needs.

She has had surgery and takes medication for the condition, but those only temporarily stop the pain. A more promising treatment is laser therapy.

Medicare will pay for high-intensity laser therapy (sometimes called "hot laser") to treat trigeminal neuralgia. But surgery years earlier replaced the stapes bone in Maryanne's right ear with a metal prosthetic. Metal and a hot laser make for a dangerous mix.

One of Maryanne's doctors has suggested cold laser therapy. She would gladly try it, and while the Food and Drug Administration has approved cold laser therapy for the relief of pain, Medicare won't pay for it as it still considers the evidence insufficient to warrant covering it.

That leaves Maryanne with few options other than drugs like anticonvulsants and painkillers.

"Cold laser doesn't have the same risks as the drugs," Maryanne says, the frustration welling in her voice. "Addiction, slowed judgment, accidents — all of those things are side effects of drugs. But Medicare will pay for those."

Medicare and the Loss of Freedom

July 30 marks the 50th anniversary of President Lyndon Johnson signing Medicare into law. At the time it was signed, government actuaries had predicted that the portion of the program that covers hospital insurance would cost $9 billion by 1990. In reality, it ended up costing $67 billion by that point — or more than 7 times the original estimate. Since its inception, the program has been dramatically expanded by both parties — even when President George W. Bush had a Republican Congress, he twisted arms to add a prescription drug benefit in 2003.

This year, the government will spend $626 billion on the Medicare program as a whole — more than is spent on national defense. In fact, more is spent on Medicare than any government program other than Social Security. A combination of the aging of the population and rising healthcare costs will cause Medicare costs to explode even further in the coming decades.

There are about 77 million baby boomers in the U.S. By 2029, all of them will have turned 65, the age of Medicare eligibility. The boomers, combined with the disabled, will swell Medicare enrollment to over 88 million by 2040, a mere quarter century from now.

By that point Medicare will consume one out of every five dollars of the federal budget (minus interest payments on the debt) according to the Congressional Budget Office. All entitlements, including Medicare, Medicaid and Social Security, will consume almost 68 percent of the budget, leaving only one-third to pay for all other discretionary spending, including defense.

Topping it off, the federal deficit (including interest payments) will be about $1.8 trillion that year. To fill that gap without touching Medicare would require either severe, immediate, spending cuts; dramatic and economically unsustainable tax increases; or some undesirable combination of both. That means in reality, Congress will likely continue to make tweaks to Medicare aimed at restraining costs while avoiding the political blowback of any true reform that addresses the program's underlying problems. But that will have consequences of its own.

As it has grown into one of the largest program's in the federal budget, Medicare has enabled government to assert unprecedented control over the doctor-patient relationship. The process that led to this level of intrusiveness happened gradually, with doctors and patients losing their freedom little by little. But, more and more, doctors and patients are finding that Medicare won't pay for treatments they want to try. Most worrisome, without serious reform, future cost pressures on Medicare will distort incentives and increasingly put doctors in conflict with their patients.

A History of Interference

When Medicare became law in 1965, the first part of the legislation was titled, "Prohibition Against Any Federal Interference." It states, "Nothing in this title shall be construed to authorize any Federal office or employee to exercise any supervision or control over the practice of medicine," a rather explicit promise that Medicare would not interfere with the doctor-patient relationship.

If this was an attempt to assuage the public, it was dishonest. A later section of the law stated that "no payment may be made under part A or part B [of Medicare] for any expenses incurred for items or services … which … are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member." That put Medicare on a collision course with the doctor-patient relationship. Inevitably some physician would deem a treatment "reasonable and necessary" that Medicare did not.

It didn't take long for that to happen. In 1968 the Department of Health, Education and Welfare (the predecessor of the Department of Health and Human Services) released regulations on Medicare reimbursement for portable X-ray services, a benefit Congress had added at the end of 1967. The regulations refused to pay for any portable X-ray that involved the use of certain dyes — called "contrast mediums" — that enhance the image of certain body parts in X-rays. This meant that portable X-rays could not be used to image gall bladders and urinary tracts. If a doctor felt his patient needed such X-rays, the patient would have to go to a hospital regardless of whether the doctor and patient felt it was more appropriate to do so with a portable X-ray machine.

Talk to physicians today about Medicare, and it won't take long for them to complain about how it interferes with patient care.

"Medicare only pays for a breast MRI under certain conditions," says Juliette Madrigal-Dersch, a primary care physician in Texas. "Either a woman has to have had breast cancer or have the gene for breast cancer to get a breast MRI. So, if a patient has an abnormal mammogram but it's really hard to see what the problem is on the mammogram image, and I think that an MRI should be the next step, Medicare makes it very difficult to get it."

In other cases it can be difficult to get a patient out of the hospital. If a patient needs to be transferred to a skilled nursing facility for rehab, Medicare won't pay for it unless the patient has spent three days as an inpatient in the hospital.

"It's a silly rule," said Eric Novack, an orthopedic surgeon in Arizona.

He recalls a patient he recently treated who had broken her ankle.

"Fixing it should be an outpatient procedure, but she was a frail woman in her early 80s who lived by herself, so she had no one who could help her get around," he said. "She needed care in a skilled nursing facility, but the only way I could send her to one, without her having to foot the bill herself, was to keep her three days in the hospital."

Not only are such hospital stays wasteful, they are potentially harmful.

"I like to tell patients that hospitals are full of sick people, and if you don't have to be around them, you shouldn't be," Novack said. "The longer you are in the hospital, the more likely you are to have other issues."

In general, the freedom doctors and Medicare patients had to decide on treatment themselves slipped away gradually, with a small change in the law here, and a few new regulations there. This way, the government would be well on its way to gaining considerable control over the doctor-patient relationship before doctors and patients realized that it had even begun. This would make it easier to take larger portions of that freedom when Medicare faced cost pressures in the 1980s.

In 1989 Congress passed a system of price controls for physician services that Medicare instituted in the early 1990s. While the old Medicare price system gave doctors a little flexibility in what they could charge Medicare patients, the new system set strict prices.

One of the unintended consequences of the new price control system was that it paid more for shorter visits than it did for longer visits. More specifically, if the pay for each type of visit is divided by the number of minutes recommended for each type of visit, the pay-per-minute for shorter visits is greater than for longer visits.

Consider two hypothetical physicians each working an eight-hour day, or 480 minutes. Physician A sees 48 patients in a day each for a 10-minute appointment for which Medicare pays him about $43.98 or just under $4.40 per minute. He will gross about $2,122 a day. Physician B sees 12 patients in a day each for a 40-minute visit for which Medicare pays him about $146.84 or about $3.67 a minute. He will gross about $1,761 a day. Thus, Physician A makes about 20 percent more than Physician B.

The problem is that patients tend to view longer physician visits as ones of higher quality, and with good reason. Research has found that longer visits enabled physicians to ask more questions and provide more information about patients' ailments and the recommended treatments. Unfortunately, Medicare's price controls, in effect, penalize doctors who try to provide better quality by spending more time with their patients.

What if patients decide that their doctors' time is worth more than what Medicare pays and wants to compensate the doctor out of their own pockets? Medicare interferes with that, too. It is illegal for a doctor who is in the Medicare program to accept out-of-pocket payment from a Medicare patient.

Before Two Midnights

Obamacare has instituted changes to Medicare that portend the future of the doctor-patient relationship. Some of those changes have already proved deadly.

In recent years, hospitals have increasingly held patients in what is known as "observation status," under which the hospital monitors a patient for a certain period of time until a physician determines that the patient can return home or has to be admitted as an "inpatient."

This posed a problem for Obamacare's initiative to reduce hospital readmissions. The initiative penalizes hospitals that readmit too many patients by cutting their Medicare reimbursement. The Centers for Medicare and Medicaid Services defined a readmission as one that took place within 30 days of the initial admission. However, under CMS rules, a patient wasn't initially admitted unless he was admitted as an inpatient. Obviously, this would give hospitals incentive to keep patients even longer under observation status.

To avoid this, CMS instituted the "two-midnight rule." Under this rule Medicare would consider someone admitted to the hospital to be an inpatient when a "physician expects the beneficiary to require care that crosses two midnights and admits the beneficiary based upon that expectation." That made it far more difficult for a hospital to keep a patient more than two days without admitting him or her as an inpatient. However, what if a patient needed inpatient care in a hospital but would not need to stay two days? In such instances, CMS had now placed its judgment over the judgment of physicians and patients.

New York City resident Frank Alfisi had no idea how this would impact him when he checked into St. Joseph's hospital in mid-November 2013. Suffering from kidney failure, he needed dialysis that he usually received at a dialysis clinic. However, he missed an appointment due to the flu. The next day he woke up feeling so ill that he needed to go to the hospital to receive dialysis. But under Medicare's rules, he couldn't receive dialysis at a hospital unless he was an inpatient. Yet dialysis only takes a few hours and thus provides no justification for a physician to admit such a patient for two days in the hospital.

The doctors at St. Joseph's ran a bunch of tests, trying to find something that would allow them to admit him as an inpatient, but their efforts were futile. Eventually, Frank's condition worsened to the point that the doctors were able to justify admitting him as an inpatient. He received dialysis, but, because of the toxins that had built up in his body, the damage was done. He was now wheelchair bound, needed portable oxygen, and had lost much of his sight.

Frank's quality of life had deteriorated to the point that he lost the will to live and decided to move into a hospice. He never made it, dying on Jan. 14, 2014, in the hospital.

Doctor-Patient Conflict

The two-midnight rule is not the only way Obamacare put doctors in conflict with patients. Obamacare also established the Center for Medicare and Medicaid Innovation, and one of its first projects was to establish Accountable Care Organizations in Medicare. ACOs are groups of healthcare providers — including doctors, nurses, and other healthcare providers — that will take responsibility for the care of at least 5,000 Medicare patients. If an ACO improves the health of its patients while also saving on costs, the providers will get to share in the savings. In theory, this will incentivize the providers in the ACO to work together to coordinate patient care.

Twila Brase, a former nurse and current president of the Citizens' Council for Health Freedom, thinks that it will turn out quite differently.

"ACOs put doctors in charge of both the treatment and payment of healthcare," Brase says. "It puts the doctor and patient in conflict with each other, especially sicker patients. The more sicker patients, the harder it is to achieve savings."

In other words, ACOs could give doctors a very stark choice. Save money or treat the patient. Right now, the Center for Medicare and Medicaid Innovation is running two ACO programs, the Shared Savings Program and the Pioneer ACO Program. In the Shared Savings Program, ACOs have a spending target they can exceed if necessary. That takes some of the pressure of doctors to save on costs by scrimping on care. The Pioneer program, though, penalizes ACOs for exceeding their spending targets. Of the original 32 ACOs that signed up for the Pioneer program, 13 have dropped out. Seven of those have joined the Shared Savings Program.

But with the cost of Medicare rising beyond the ability of taxpayers to pay for it, pressure will be on Congress to make the future of ACOs look more like the Pioneer program. Already, legislation to that effect has been introduced by Sens. Ron Wyden, D-Ore., and Johnny Isakson, R-Ga. Called "The Better Care, Lower Cost Act of 2014," it would give ACOs a capitated amount — i.e., a fixed amount — to spend on each patient.

"If the ACO only has a certain amount of money to spend on all of its patients, then doctors will have to be concerned about how much they have to spend on a patient's care, and how much they can delay your care so that the ACO doesn't run out of money before the end of the year," Brase notes. "It puts the doctor in an adversarial relationship with patients, especially with a patient who isn't healthy."

This is where a government healthcare program like Medicare inevitably leads. As the program's costs exceed the means to pay for it, expenses must be reduced. Members of Congress will, of course, reduce Medicare's costs in ways that cause them the least amount of political trouble.

That means the sickest Medicare patients who will suffer the most because they are the most politically powerless. First, relatively few people get seriously ill each year, too few to have much impact on congressional elections. Second, because they are ill, they are in no condition to be organizing, protesting, getting media attention and the other things that can compel Congress to change Medicare policy. Finally, some of them are so ill that they won't be around much longer to cause Congress any headaches.

This doesn't have to happen. There is a way to reform Medicare that reduces costs and restores the doctor-patient relationship. It involves giving Medicare patients direct control over the money Medicare is spending on them.

Specifically, all Medicare beneficiaries should be given large Medicare accounts out of which they will pay for their healthcare directly. For indigent patients, Medicare will pay for any expenses above that amount. Everyone else on Medicare will have to purchase private insurance to cover anything beyond the size of the account, much like private Medigap plans currently cover Medicare's cost sharing.

Medicare beneficiaries will get to keep a percentage of any money left over in their accounts at the end of the year. This will encourage Medicare patients to become consumers of healthcare. They will have incentive to be more careful in how much care they use and to take better care of their health as both will mean they get to keep more money for their Medicare accounts.

It will also incentivize doctors and other healthcare providers to find ways to provide more cost-effective care as there will be millions of Medicare patients who will be looking for care that provides better quality at lower costs.

Finally, large Medicare accounts will restore the autonomy of the doctor-patient relationship. When Medicare patients are put in control of Medicare's resources, it is they, along with their doctors, who will be able to decide the best course of treatment, not the federal government.