The political lore of the 1964 presidential campaign has a reporter asking an elderly woman why she was supporting Lyndon Johnson over Barry Goldwater. Goldwater, she answered, wants to abolish TV. Actually, the reporter corrected, Goldwater wants to abolish the TVA. To which the woman responded: “Well, I’m not taking any chances.”

The voters of New York’s 26th Congressional District last week were not taking any chances. Republicans have no more proposed the abolition of Medicare than they have proposed the abolition of medicine. But this setback for the GOP’s Medicare reform campaign illustrates the difficulties ahead.

Conservatives should understand that much of the opposition to Medicare reform is conservative, at least in form. It is rooted in a fear of change and a resentment of meddling officials. A general distrust of politics extends to a distrust of politicians engaged in confusing reforms. In a choice between the status quo and major change, a center-right country generally will choose the status quo.

So all Republican arguments in favor of Medicare reform ultimately depend on the success of one argument: that the status quo is not an option. This contention has the virtue of being correct. About 80 million baby boomers are entering a system designed for a time when people died earlier, unattended by expensive technologies. Demographic shifts and rising per capita costs require health entitlements to change or collapse. And President Obama has complicated the problem by adding another health entitlement, partially funded by resources taken from Medicare.

Medicare as we know it will be insolvent in a decade. Politicians who propose no solution are allowing the system to collapse for their temporary political benefit. Taxes sufficient to prop up the status quo would take a crippling portion of the economy, leaving individuals, families and businesses with dramatically fewer resources to address their needs. Some Democrats advocate strict price controls within the current Medicare structure, overseen by a board of 15 bureaucrats. But cost-cutting by bureaucratic fiat usually doesn’t work. When it does, the result is rationing. Republicans propose government premium supports to fund the individual purchase of health insurance. This would increase out-of-pocket costs for most in the middle class — making them more conscious of their health expenditures — while preventing a Medicare crash.

None of these answers is particularly appealing. A free lunch would be preferable. It isn’t available.

As Republicans make this unappetizing case, they will need to keep a few things in mind.

First, Rep. Paul Ryan’s Medicare reform plan is admirable, even courageous, but not the final word. The subsidies he proposes may well be too small to be a realistic alternative to the current system. Republican presidential candidates will need some leeway to make their own recommendations. This is not heresy; it is strategy. The problem with Newt Gingrich’s initial criticism of the Ryan plan was Gingrich’s hyperbolic tone. Triangulation is different from trash talk. Tim Pawlenty did it better: “I think in general the direction of [the Ryan proposal] is positive, but I’m going to have my own plan.”

Second, Republicans will need to couple their Medicare message with an emphasis on economic opportunity. No matter how well the need for austerity is explained, the audience for austerity is limited. Genuine foot-stomping, hat-throwing enthusiasm for entitlement reform is mainly confined to half-filled conference rooms addressed by former senator Warren Rudman of the Concord Coalition. The most fetching Republican promise is a growing economy that rewards work and enterprise, including for those lower on the economic scale.

Third, the GOP will need to assemble an unusual political alliance in favor of entitlement reform. Unconstrained entitlement spending is a threat not only to the economy but also to every other category of spending by the federal government. As the share of the budget consumed by mandatory programs rises above 50 percent — and a larger portion of the budget goes to service interest on the national debt — only scraps will remain for other priorities. Want federal spending on food stamps? Or on national defense? Or on foreign assistance or education or highways? In the absence of entitlement reform, every discretionary program will be engaged in a death match to secure dwindling resources. An entitlement reform coalition should include anyone who wants federal spending on anything other than entitlements. To construct this coalition, Republicans will need to appeal to groups beyond the conservative comfort zone.

The Republican push for entitlement reform will be creative, flexible and persistent — or it will fail.