he last time I checked, there were 486,000 Medicare beneficiaries in the somewhat politically significant state of Iowa and another 168,000 in its equally prominent sister, New Hampshire.
And it's possible that they and the tens of thousands of people right behind them in age might be interested in what the Democratic presidential candidates have to say about this vital piece of twine in the social safety net. To oversimplify only slightly, there's Al Gore (a great deal), and there's Bill Bradley (next to nothing).
Those Medicare numbers are expected to double over the next 25 years as the baby boom generation ages. In particular, remembering that advanced age inevitably means sharply higher medical expenses, it's worth noting that the 85-and-older populations (now 64,000 in Iowa and 18,000 in New Hampshire) are going to triple over the same period. And if the past is prologue, roughly 60 percent of these seniors will be women.
The future health of Medicare is thus on its graying face as big an issue as you can find in public policy, especially because (as with Social Security) the ratio of workers paying taxes to seniors receiving benefits is certain to shrink dramatically.
And in the Democratic Party, which fought for Medicare for more than 20 years, enacted it in 1965, and has led the fight to preserve it against the malign intentions of budget-cutters and privatizers, you would expect ideas galore about a cherished legacy with an uncertain future looming. You would only be half-right.
On Medicare, the bold guy with the big ideas turns out to be Gore, and the guy who comes up shooting blanks turns out to be Bradley.
On the issue, Gore is Clinton plus a lot. The core of his proposal is that $370 billion be reserved out of non-Social Security retirement surpluses over the next decade, for seniors' health care, and that 15 percent of the surpluses be similarly reserved for at least another five years after that. Some $300 billion would be reserved for the protection of the hospital insurance trust fund, or Part A of Medicare, that would otherwise become insolvent in 2014-15. The remainder would help pay for his sound targeted prescription drug benefit, in marked contrast to the Bradley drug proposal, which combines the worst of two worlds - an open-ended entitlement on the back end and too many deductibles and co-payments hurting the truly needy on the front end.
As President Clinton would say, this is a huge deal. By reserving such a sum of money over 15 years, Gore would extend the hospital insurance fund's solvent life as is for another dozen years. That doesn't make ''reform'' unavoidable when the demographic time bomb goes off, but it does mean that it can be a lot less wrenching in a program that any senior can tell you is not exactly famous for its munificence right now. Indeed, its arguable that Clinton-Gore has already made most of the tough choices.
People forget, but when the administration took office in 1993, the insolvency date looming for Medicare was this year. Actions taken that year and in 1997, focusing on hospital, nursing home, and home health care providers - along with the greatly improved economy - pushed the date back. But some of the squeeze was too tight, threatening quality of care, and so some of the funds were restored in the bipartisan budget deal last month.
That's why using the surpluses boldly as well as prudently (on this topic the two adverbs go together) is so vital and Gore's commitment so important. Not surprisingly, he asked Bradley in the New Hampshire debate last Friday for details of his own Medicare thinking, and got zip in reply.
Instead, Bradley relied on three points he's been making all fall, with underwhelming results. The first is an accurate claim that in his 18 years in the Senate on the Finance Committee he defended Medicare against its critics. That claim is now the full content of a 30-second TV ad that just started running in Iowa, a defensive move that shows his campaign's legitimate fears.
What Bradley doesn't like to say is that he would not set aside a red cent to protect Medicare. Instead, he expects that coming advances in disease control will bring Medicare costs down over time. That argument impressed people when he first made it, but Bradley has never fleshed it out with supporting detail. That makes it a riverboat gamble with Medicare's security, and that's unacceptable.
His third point is that if the economy should grow faster than expected in future years, there could be more money available that could be set aside to extend Medicare's solvency. But that point betrays Bradley's horribly misplaced sense of priorities. To him, Medicare is essentially an afterthought; it brings up the rear. To Gore, Medicare is at the very top with Social Security, where it belongs.
Maybe Bradley would have had room for Medicare had his broader health insurance proposal not squandered billions on tax deductibility for insurance premiums paid by the wealthy and on subsidies for workers miles beyond the poverty line who already have health insurance. It is astonishing that two out of every three Bradley dollars would go to those who already are insured.
Gore doesn't make that mistake. On Medicare, Bradley's proposals don't match his professed caring.
Thomas Oliphant is a Globe columnist.
