Sen. Bob Dole told the American Conservative Union on Oct. 26 that he was one of 12 House members who voted against Medicare in 1965 "because we knew it wouldn't work."

But Medicare has worked and worked well for 30 years. It needs some changes, which should not be surprising after all this time. But let's look at what Medicare has accomplished.

By spreading the cost of medical care for the elderly among all working families, Medicare has made that cost bearable. It has saved millions of families from having to face, one-by-one, the huge cost of hospital care for their elderly relatives. And Medicare has meant longer life for the elderly. Although U.S. longevity statistics overall are nothing to brag about, we rank first (along with Japan) in longevity after age 65.

Perhaps even more important, Medicare makes living longer worthwhile. Procedures that many of the elderly could not possibly afford on their own--joint replacements, cataract removal, and cardiac bypass operations, to name a few--have become broadly available.

It is true that Medicare costs more today than was anticipated in 1965. But that's true of all health insurance. Increasing knowledge of diseases and their causes and technological advances have transformed the care that all insurers are paying for. Health care today is much more effective, and much more expensive.

Medicare costs over the long run have not increased as much as costs in the private sector. But Medicare's costs are more visible because Medicare, alone among insurers, tries to predict costs far into the future. Private insurers and self-insuring employers usually estimate costs for only a year or two at a time. When they miss the mark--as they often do--it doesn't look nearly as big as a cumulative error in, say, a 25-year estimate.

Medicare, until recently, was doing better than private plans at holding down costs and led the field in developing cost-saving approaches that have since been widely adopted in the private sector. From the beginning, Medicare required hospitals to improve their record-keeping and insurers with whom it contracted to improve their claims processing. And today, private insurers are learning from Medicare's electronic claims processing.