Joe Klein: There are two possible roadblocks here. One is that the Insurance companies and business may not play ball if the Democrats insist on a Medicare-like public option. That's very much on the table in the House side, perhaps not so on the Senate side.

And then the other problem is the one you always have with entitlements and that is that the costs are going to be enormous. And you see the president doing something very courageous, I think, which is that he's beginning to talk about limiting the sorts of operations that might be appropriate. The other day he talked about his grandmother who was given a hip replacement when she was a terminal cancer patient. Those are very, very difficult decisions, but they are going to have to be part an parcel of this plan.

Andrea Mitchell: That's basically rationing. That's what it's going to come down to.

Klein: That's right.

“I don’t know how much that hip replacement cost,” Mr. Obama said in the interview with David Leonhardt of The Times. “I would have paid out of pocket for that hip replacement, just because she’s my grandmother. Whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else’s aging grandparents or parents, a hip replacement when they’re terminally ill is a sustainable model is a very difficult question.”

He went on to say: “If somebody told me that my grandmother couldn’t have a hip replacement and she had to lie there in misery in the waning days of her life, that would be pretty upsetting.”

At the heart of the health care debate that will soon occupy Washington is just that conundrum. As an intellectual matter, it’s one thing to say that it makes no sense for a country to spend so much on procedures that ultimately will do little to extend or improve the lives of those nearing death. But as a personal matter, it’s another to deny your own grandmother an operation that may at least make her last days more comfortable.

Some conservatives have cited Mr. Obama’s story to make the case that his plan to expand access to health care and reduce costs ultimately will result in rationing, of the kind that might have denied his grandmother the surgery unless she paid the bill on her own.

“To me, Obama is laying out the intellectual case for health care rationing while acknowledging the potential human costs of such a policy,” wrote Matthew Continetti on the Web site of the Weekly Standard magazine. “He’s saying that, in order to contain costs, under a universal health care program his grandmother might have been denied that hip replacement, or forced to pay for it herself. This is the natural consequence of a universal policy, which would bankrupt the country without some form of rationing care.”

Advocates on the other side of the debate reject the label. “I think Obama was trying to invoke the notion of tradeoffs more than rationing,” said Len Nichols, who directs the health care program at the New America Foundation, a Washington research organization. “Curative care for his grandmother was futile. Rationing is when efficacious care is denied to save money, perhaps to provide basic care to another, but nevertheless consciously denied.”

Drew Altman, president of the Henry J. Kaiser Family Foundation, said that nothing envisioned in the current health care legislation would take decisions about end-of-life care away from patients or doctors.

“One of the great lessons of the Clinton debate was not to scare the public that health reform would change their current medical arrangements,” he noted. “Health care is front and center again because of the problems average Americans are having paying their health care and health insurance bills in the middle of a recession, and that’s the core problem health reform legislation has to address.”

Obama's health care reform is bad news for seniors