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Much of the current debate about expanding health insurance coverage avoids addressing an uncomfortable trade-off: with a limited budget, making benefits more generous means being able to cover fewer people. Moreover, designing insurance benefits that are limited to coverage of higher-value care but are extended to more people will generate greater improvements in health than providing unlimited care for fewer people. Policymakers and patient advocates are reluctant to acknowledge that in a world of scarce resources it will not be enough to eliminate waste: we will have to make active choices in our public insurance programs between increasing the number of people covered and increasing the generosity of that coverage.