Medicare is America’s gold health standard, right? It is a shining example of success, eclipsing its fraternal twin, Medicaid, to the extent that health-care proposals not clearly related to either are rather successfully branded as “Medicare-for-all.”

However, elderly women might be the first to question that characterization. Medicare alone has proved inadequate for the needs of many elderly people, especially in the ranks of the “oldest old,” or those over 85 years of age. And given the drastic gender imbalance in life expectancy and a range of health and economic factors that hit women harder, the gulf in elderly health care becomes a women’s health issue as well.

First of all, the good. In just over 50 years of existence, Medicare has been the key force behind America’s health-care modernization, changing not only the way the country delivers health but also dramatically reducing poverty rates by providing a cushion between retired seniors and the ever-widening abyss of health-care costs.

An article in Generations: Journal of the American Society on Aging published last year indicates that this explicit lifeline for seniors was also an implicit lifeline for women. Women have always lived longer than men, but of course they have never received the same employment benefits. Medicare and its partner, Social Security, helped provide women with guaranteed income during their longer lifespans, accommodated somewhat for lower or nonexistent pension funds, and provided some stability after the likely probability of widowhood. As women have also always been much poorer than men, the poverty-lifting effects of Medicare were felt most along gender lines.

While its positive effects are certainly noteworthy for elderly women, Medicare just doesn’t seem to have the horsepower to accommodate their longer life spans and higher rates of poverty to anywhere near the point of gender equality. The list of services that Medicare does not currently provide––dental care, hearing aids, non-medically necessary foot care, home health services, long-term supports, nursing homes––may sound like unnecessary and costly miscellanea when compared with many private insurance plans. But the oldest segments of the Medicare population suffer from issues like chronic diseases, disabilities, and dementia that make these services indispensable. And given that women make up 67 percent of those over 85, that they are more likely to suffer from these issues than same-aged men, and that they suffer worse effects from diseases like dementia, they are by far the most likely to be left in the cold.

Essentially, for aging women, the pie of health-care costs grows on a steep curve, while the slice of the pie that Medicare pays for diminishes. On average, Medicare only pays for half of medical costs, even though there are a few ways to fill in the gaps. Many turn to Medicare Advantage plans and other private insurance providers for necessary services.

However, this setup can be extraordinarily expensive, as most Medicare services require copayments or co-insurance in addition to the premiums for supplemental insurance. High drug prices and the infamous-but-shrinking “donut hole,” all impact seniors’ pockets as well. While poor and low-income people who also qualify for Medicaid are eligible for dual coverage that takes care of most issues, poverty versus unaffordable care seems like a fairly hellish dilemma.

Might this disparity in elderly women’s health be affecting the primary elections? Given the aforementioned demographic skew in aging and the granularity limits of polls, it is hard to entirely extract gender from age and health. But in the Democratic field, where health-care polls as one of the four most important issues to voters, Hillary Clinton’s strongest footholds have been elderly people, women, minorities, and people in the sickest states. Clinton scores consistently as the candidate voters trust most on health care over her rival, Senator Bernie Sanders.

While both candidates are rather thin on concrete proposals to solve the specific health problems of elderly women, Sanders’s health-care plan may actually hurt him in relation to Clinton. “Medicare for all” does not actually entail Medicare for all; rather, it would replace all insurance with a more comprehensive single-payer option that would beat Medicare’s cost issues with a healthy mixture of risk-pool expansion, taxes, and unobtanium. But the name does help Sanders sell it to the general public, as it polls far better than any relevant synonyms.

However, seniors are down on universal government-run health care, with only one-third supporting it in a February Kaiser Family Foundation tracking poll. Therein lies the rub: Seniors, especially women, know the limits and shortcomings of the consumer side of the government health-care system better than anyone. Sanders’s plan does make noise about long-term and end-of-life care, but a dose of skepticism well informed by experience might limit his inroads among seniors. The devil is in the details, and as costs are the true limiting factor for the current major government-run health system, a proposal for a new one that doesn’t fully elucidate the nuts and bolts of costs and payment suffers.

Unfortunately for the people who are at the end of Medicare’s rope, there is no silver bullet campaign promise elsewhere. Clinton’s own plan promises to defend gains made in the Affordable Care Act and to fix drug prices, as well as to encourage delivery-system reforms that can help coordinate care services. It is hard to imagine these reforms being enough to address the wild extremes of costs, poverty, and illness that can ruin elderly women’s finances and health. On the Republican side, the only policy options are either standing pat and waiting to make painful, nebulous cost-cutting reforms such as voucher systems or eligibility-age hikes or making them up front and passing the pain to seniors now. None of these options lays out a true pathway to health-care affordability for elderly women.

As is the case with many health issues that mostly affect women, there is an undercurrent of gender autonomy and women’s rights here as well. Younger elderly women who are already confronting financial or health issues often become caretakers for older mothers or female family members. Medicare reforms could help break this cycle and reduce generational dependence on women as caretakers. Also, more extensive health-care supports for the oldest among us would further untether women from the pensions of male partners and family members and would lessen the burden of male deaths. Above all, reforms would be a major source of health and economic empowerment to women and could help continue the economic equalization that Medicare helped spark.

Challenges like those facing elderly women are one of the key points of a rigorous nationwide elections process. Primary races function as a sort of policy lab to propose and calibrate ideas that might solve problems faced by certain demographics. And while the answer hasn’t fully emerged yet, there is time left. Perhaps a Republican candidate in danger might propose a working plan that is co-opted by the winning candidate. Perhaps someone between Clinton and Sanders might make the math work. But as the elderly population balloons, and as differences in life spans and earnings between men and women persist, the issue of Medicare’s costs won’t be fading away soon.