News filtered in late last week that after major political rumblings nationally, House Republicans are backing away, for now, from Wisconsin Rep. Paul Ryan's plans to shift Medicare, starting in 2022, to a new system based on a Medicare payment enabling beneficiaries to buy private insurance.

Recent opinion polls have reported that Americans are divided on substantive changes to Medicare, even after they're apprised of Medicare's long-term fiscal projections and its impact on overall federal spending.

But I don't want to get bogged down in the details of our looming national fiscal problems. Thinking 20-30 years out about health care costs can be overwhelming, but it's also an opportunity to think about how Medicare and health care providers can serve future generations of beneficiaries, especially in light of ongoing transitions in how care is delivered. In a recent H&HN Daily column, contributor David Ellis predicted if current trends in care delivery continue, telemedicine services and outpatient services will gradually supplant acute care services. In the future, Ellis predicts, hospitals may "downsize to the point where (unless they diversify) they will provide only advanced trauma and critical care."

It's an interesting future scenario, and one that opens up a series of questions not just about future care but about how Medicare and private insurers will pay for it. If, indeed, we're going to be spending more time accessing care outside of the hospital, who will emerge to organize these services, and how will Medicare and private payers deal with an explosion of new providers and existing hospitals jumping into these new markets? Also, if the promise of personalized medicine, and its vision of having clinicians and health coaches use our genetic profiles along with our medical histories to help determine our care and health choices, ever materializes, how will CMS and private insurers pay for and rate those services? And what role will wellness programs play in the Medicare program of the future?

Although I'm still a few decades away from becoming a Medicare beneficiary, I like the idea of a system that offers a wider variety of services outside the acute care setting—while ideally preserving and helping to pay for those services when I need them. And I don't mean to downplay the tough and painful decisions Americans will have to make about Medicare in coming years, as the combination of retiring Baby Boomers and rising health care costs looms. But amid all the nightmare scenarios of looming collapse, it's instructive to step back and think of what Medicare might do for us in 2040, as opposed to what it might do to us.

Email your thoughts on what Medicare might offer in 2040 to