A young republic once fought over pennies for soldiers' back pay, and now its heir debates whether to devote 35 billion to a class of fashionable medicines without a fully reckoned balance sheet. I do not deny the economic logic of preventing disability, but I distrust any policy that enlarges federal commitments on the strength of industry projections and voter desperation. If we are to harness Medicare and Medicaid for this purpose, the terms must be clear, the prices hammered down with the vigor of a treasury auction, and the sunset clauses written in ink, not sentiment. Otherwise we risk fastening yet another permanent claim upon revenues that are already overpromised.