We’re told that we’re on the precipice of coming to a great reckoning with our major health care programs. Medicare and Medicaid are bloated and must be brought to heel. The truth is we’re already going through that reckoning. We’re already cutting back on these programs. The federal government just leaves it to the states to make the cuts in the case of Medicaid.

Banned from tightening Medicaid eligibility in recent years, many states have instead slashed optional benefits for millions of poor adults in the program. Teeth have suffered disproportionately.

Republican- and Democratic-controlled states alike have reduced or largely eliminated dental coverage for adults on Medicaid, the shared state and federal health insurance program for poor people. The situation is not likely to improve under President Obama’s health care overhaul: it requires dental coverage for children only.

Illinois became the latest state to drastically cut dental benefits last month, when Gov. Pat Quinn, a Democrat, cut $1.6 billion out of its $15 billion Medicaid budget, reducing adult dental coverage to emergency tooth extractions. The state, whose Medicaid program was considered among the most generous, also cut vision benefits, eliminated chiropractic and podiatry coverage and started requiring co-payments for drugs.

Fortunately, it’s not like people need their teeth for any reason.

States have to balance budgets, and states basically pay for two things – public schools and Medicaid. So during the Great Recession, when their tax base shrunk, they were going to have to sacrifice one or the other or both. And that’s been the plan in both red states and blue.

Whether every state takes the Medicaid expansion or not – another large state, Georgia, just vowed to opt out this week – they’re going to have some flexibility in designing the program. They’re going to have their own way of administering drug coverage and vision and dental and other services not on a mandatory menu. And as long as there are budgets to balance and tax cuts to deliver, services will be cut. In addition, doctors will drop out of offering Medicaid if they can survive on the higher reimbursements from private insurance subscribers.

This is the inevitable outcome of an unintelligently designed system. And Obamacare, far from the “central planning” of Paul Ryan’s fever dreams, doesn’t make this system all that much more intelligent or coherent. People don’t really care whether they get their health coverage from an entrepreneur or the government. They care about the quality of the benefits and the quantity of the cost. And every modern health care system ever devised in the world has proven utterly that the best quality at the lowest quantity comes from a coherent system with a single payer. It isn’t even close.

That’s another part of this “great debate” that won’t be debated. We’ll hear about private choice and competition, versus managed… private choice and competition, along with an alphabet soup of public programs. Coherence and simplicity and the kinds of measures that get us to the highest-quality program at the lowest cost won’t enter the debate.