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Medicare is almost always a big issue in presidential campaigns. That's because the huge federal health care program is important to seniors. And seniors, who vote in disproportionately high numbers, are important to presidential candidates. But this year, the candidates are playing down Medicare compared to campaigns past. NPR's Julie Rovner explains why.

JULIE ROVNER: It's lunchtime at the Upcounty Senior Center in Gaithersburg, Maryland. And between bites of chicken and green beans, the 100 or so seniors here are happy to talk about two of their favorite subjects: health care and politics.

Blanche Keller(ph) says she's not surprised that Republican presidential candidate John McCain and Democratic hopeful Barack Obama are spending most of their time on the stump talking about the economy.

Ms. BLANCHE KELLER: Because it's hitting people everywhere. The gas, the price of gas, the price of food, price of - and not being able to sell your house. All those are big things for people.

ROVNER: But when it comes to Medicare, Keller, who's a retired federal employee, has but a single message: Keep your hands off.

Ms. KELLER: Don't mess with it. And if it ain't broke, don't fix it, you know?

ROVNER: Unfortunately, Medicare is broke, or it soon will be. Between rapidly rising health-care costs and 78 million baby boomers who start becoming eligible for the program in just two more years, both Senators McCain and Obama recognize that the program needs to be put on firmer fiscal footing.

McCain has been traveling the country quoting the former head of the Government Accountability Office.

Senator JOHN McCAIN (Republican, Arizona; Presidential Candidate): I'm tired of laying a $30 trillion deficit on future generations of Americans. I refer to David Walker. He says that in several years, we will pay - 70 percent of our taxes will go to two programs: Social Security and Medicare and Medicaid. That's not sustainable, and yet we continue to mortgage our children's futures.

ROVNER: Obama says he's not as worried about Social Security...

Senator BARACK OBAMA (Democrat, Illinois; Presidential Candidate): But the problem of Medicare and Medicaid, which are in crisis, if we don't deal with soon, we're going to be making our children and our grandchildren poor.

ROVNER: Both candidates also recognize that fixing Medicare can't be done in a vacuum. It must part of an overall change to the health system at large. But that's where they part company.

McCain has proposed a major overhaul of Medicare's payment system, paying health care providers not by each individual service they perform but by how successfully they treat their patients. He hopes that could serve as a model for private insurers.

McCain has also proposed making wealthier Medicare beneficiaries pay more for their benefits, starting with the new prescription drug benefit. He voted against that program in 2003 on the grounds that it served people who didn't need it and added to Medicare's long-term financial problems.

Sen. McCAIN: People like Bill Gates, Warren Buffett don't need their prescriptions underwritten by taxpayers. Those who can afford to buy their own prescription drugs should be expected to do so.

ROVNER: Obama, on the other hand, wants to expand Medicare, in a sense, making a Medicare-like program available to those under age 65 who don't have insurance. He also wants to help bring down the price of drugs under that new Medicare benefit, saying - as most Democrats do - that it's now way more expensive than other government programs, like the one in Veterans Affairs.

Sen. OBAMA: Now, if you take Zocor, you're paying about 10 times what those in the VA system pay just because the VA system was allowed to negotiate for prescription drugs, and the Medicare benefit, we decided wouldn't do it. That, obviously, is an enormous mistake.

ROVNER: Most budget analysts, however, say price negotiations won't bring down the price of drugs very much, and health policy analyst Marilyn Moon of the American Institutes for Research says McCain's proposal to charge wealthier beneficiaries more probably wouldn't fix Medicare's finances, either.

Dr. MARILYN MOON (American Institutes for Research): It's not going to save you a lot of money until you start to pull down what you treat as high income to a much, much lower level than most people think of as high income. To get substantial resources, you'd have to talk about making changes that would affect people who have incomes of $50,000 or less.

ROVNER: In fact, says Moon, when it comes to fixing Medicare, there really are only painful choices.

Ms. MOON: Somebody is going to have to take a hit. It's either going to be taxpayers or the beneficiaries of the program or the people who provide the services. Nobody wants to tackle any of those groups because they're all going to scream very loudly if they suddenly have to bear a lot of the burden of the future of Medicare.

ROVNER: Which may explain why the candidates are being as soft as possible about their Medicare plans on the campaign trail. Julie Rovner, NPR News, Washington.

MONTAGNE: And to read more about where the candidates stand on domestic issues, check out npr.org's election coverage.

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