WASHINGTON -- Just by plucking two states out of the air -- say, Iowa and New Hampshire -- you can understand why the Bill Bradley-Al Gore argument over health care is not about nothing, especially where the most vulnerable are concerned.
In terms of Medicaid, the safety net that is there for everyone, there are more than 300,000 beneficiaries in the first caucus state and more than 100,000 in the first primary state. In fact, everybody has a stake in Medicaid, whether they think of themselves as health care consumers, taxpayers, nursing home residents, or the disabled.
Vice President Gore wants to take Medicaid and build on it, working through the states to add people and improve coverage as a major means of slashing into the number of Americans with no access to affordable health care and insurance.
The former New Jersey senator wants to take a wrecking ball to the whole system. Bradley might be onto something - if he were offering something better, but he's not. Instead, he's offering the snake oil of vouchers to those for whom Medicaid means basic health care services (more than 30 percent of the live births in Iowa and more than a quarter of the live births in New Hampshire, for example).
For the people who have access to long-term care under Medicaid, including the disabled and the elderly in nursing homes, he's offering dependence on the rarely tender mercies and typically stingy budgets of state governments in return for a federal assumption of the portion of Medicaid that serves the needy.
For three months Bradley has had a chance to lead a national dialogue about health care, to build on the promising notions he first floated in an effort to move the country toward genuinely universal coverage at responsible cost.
And he's blown it. By sticking to proposals that have huge holes in them, Bradley has made the prospect of change a threat to everyone, whether they're currently covered or not. He likes to disparage Gore as ''timid'' and incremental, but the vice president has ideas than can make the system better by a mile.
Bradley's vouchers make the case. At first, his proposal offered to pay the entire premium for all adults below the poverty line (via a refundable tax credit paid in advance) to get insurance either through their workplace or by making the federal employees system available to all. But when cost concerns were raised, Bradley shifted and said the benefit would be capped.
For a single adult with income at the poverty line, the insurance premium cap would be $1,800 a year.
What can you get for $1,800? Next to nothing.
Of all the scores of choices available in the model system for federal workers, fully 95 percent cost more than that; in fact, well over half cost more than $2,400 a year. The choice most frequently made by workers -- standard Blue Cross/Blue Shield -- costs more than $2,830. In fact, if you browse the Bradley campaign's Web site, you will find the notation that the average cost of an individual option under the federal plan is more than $3,300.
This is worse than snake oil. Keep in mind that for more than 220,000 kids and adults in Iowa and more than 75,000 in New Hampshire, this is life itself.
Bradley offers an even lousier deal to the disabled. In the case of AIDS patients, for example, fully half currently receive care under Medicaid. For them, $1,800 isn't even peanuts.
The Bradley response is a suggestion that assigned risk pools in a universally expanded federal employee system would provide adequate protection and care. In a pig's eye; in fact, this would be just one way that system could be overloaded with desperate people, sending costs and premiums through the roof for everyone. For the disabled, the answer is improved Medicaid, not false promises with huge hidden costs.
Medicaid also funds the care of two out of every three residents of nursing homes. It pays half of all these rapidly increasing costs, which average $41,000 a year; and it pays two of every five dollars spent on long-term care. More than that, after hard-fought political battles, Medicaid offers quality-control regulations, not to mention other rules that keep the relatives of patients from having to spend themselves into poverty to be eligible for assistance.
That is why no governor in his right minds -- and that includes Democrats Tom Vilsack in Iowa and Jeanne Shaheen in New Hampshire -- has jumped to endorse a scheme that would turn this ticking fiscal time bomb over to the states.
To Bradley this is all scare tactics, politics as usual, unworthy of his lofty, high-concept, principled discussion of the great issues of our time.
Baloney. What Medicaid shows, what broader discussion of health insurance has already shown is simple. Bradley is wrong and Gore is right.
Thomas Oliphant is a Globe columnist.
