Health Care on the Mississippi, Part II

Real people and the candidates' plans

This is the second in a series examining how the candidates’ health care proposals will affect ordinary people and how the press could cover that angle. The entire series is archived here.

James Bell III and James Bell IV

Father and son walked into the Dr. Vesudevan Wellness Center, a Delta Area Health Education Center jointly funded by the state of Arkansas and the federal government. The elder James, age sixty-two, looked healthy; his son, age forty-three, did not. James Bell IV was a diabetic and had been for eleven years. He had trouble breathing, and it was almost hard for him to talk. He said he hadn’t seen an eye doctor in years; his feet were numb and often swollen, making it hard to stand or walk,or hold a job. He had thought about applying for a job at Wal-Mart, but a worker there told him the company might not hire him because he was so sick. His HBA1C level, a marker of how well the disease is controlled, registered a nine—too high, and he knew it, but he had no insurance or money to buy the insulin and the test strips needed to monitor and control his blood sugars.

The Bells had been to a health clinic in another town, but it had no insulin to give out and wasn’t much help otherwise. “They’ll give you a meter (to test your blood) but not the strips,” said James the younger. Strips cost eighty dollars for a supply of 100. A doctor’s visit costs thirty dollars, but to someone without money, it might as well be thirty million.

His father, who works two jobs as the county’s head jailer and as a grill cook on the night shift at McDonalds, was trying to help, but his own income is only about $30,000 a year before taxes. At least he has health coverage—a 70 percent, 30 percent arrangement. The insurer pays 70 percent of a bill; he pays 30 percent, along with copayments for doctors’ visits and premiums totaling $480 a month. (Add to that another $30 for blood pressure medication.) His wife of forty-four years has no coverage, as he can’t afford to add her to the policy.

The health center helped the younger Bell apply for assistance from a drug company that makes medicines available to the very poor; he qualified for both insulin and test strips. Abbott Laboratories was willing to give him free strips as long as he applied for Medicaid and was rejected. He was. In Arkansas, single men without children generally don’t qualify for Medicaid. Getting to a doctor regularly, though, is problematic. “I don’t have any money to take him,” says his father. “I’m just broke.” What spare cash he once had, he used to send his youngest daughter to college. Still, he was planning to use eighty dollars from the $570 paycheck he would get the next day to buy test strips for his son to tide him over until Abbott’s supply arrived.

How they would fare under McCain.

Neither father nor son would fare well under McCain’s proposals. Bell the elder would have to pay taxes on the value of his health insurance benefits. Economists argue that removing the tax exclusion for employer-provided benefits is a move toward equity, since the exclusion now favors highly paid people who get rich benefits. Equity or not, Bell would have to find the money to pay the extra taxes on an income that hardly covers the essentials. In exchange, he would get a $2500 tax credit to buy his own coverage, as an incentive to leave the county’s health plan.

The flat tax credit would favor younger people, enabling them to buy more coverage; policies in the individual market cost less if you are young. Using the credit, Bell might be able to spend less on premiums for an Arkansas Blue Cross Blue Shield policy with a $1000 deductible and 20 percent coinsurance—if the carrier would insure him at all and if it didn’t tack on a 50 percent surcharge for having high blood pressure and being overweight (as measured by the insurer). Under McCain’s scheme, insurers would not have to cover people who are already sick.

Bell the younger would have the same problem. Even with the $2500 tax credit and additional federal subsidies, most likely he would still be uninsured. His diabetes makes him uninsurable. McCain proposes putting people like him in a special high risk pool for the sickest of the sick, where premiums would be sky-high and benefits may be limited. Without an income to pay the premiums required by the high risk pool, or very generous subsidies, it’s hard to see how this would be much of an option. Bottom line: James Bell IV would still have troubled getting needed care.

How they would fare under Obama.

Neither father nor son would be required to buy insurance. The elder Bell could keep his coverage, which will probably get more expensive. Although Obama has promised that he would lower the cost of premiums by $2500 for the typical family, health analysts dispute whether this is achievable. Obama talks of a public plan option: Medicare-like coverage that people could choose instead of buying from commercial carriers. Whether this option will be cheaper depends on who provides the coverage.

If the government offers the benefits, as it does for Medicare, it’s possible that Bell’s premiums and other out-of-pocket expenses could be lower. There would also be a uniform comprehensive benefit package. If private insurers, with their high marketing and administrative costs, offer the benefits, then it’s not clear which option would be preferable. Too much is unknown, and, as the Democratic Party’s platform notes, all this will be thrashed out in the legislative process anyway.

Bell the younger has a shot at getting the consistent, ongoing care so necessary for diabetics. Under an Obama plan, he might be able to choose coverage in the public plan, assuming subsidies that are high enough to cover the premiums. If by some chance the legislative sausage grinder turns out a provision for automatic enrollment in existing public plans, like Medicaid or the State Children’s Health Insurance Program (SCHIP), he would qualify, giving him fairly comprehensive benefits and a way to pay for care. All this assumes, of course, he can still pay the modest copayments that would likely be required, and that the federal government offers the states enough funding to provide additional coverage for currently ineligible people like Bell the younger.

If a public program doesn’t come out of the legislative give and take, or if insurers are successful at maintaining their ability to turn away bad risks like Bell, he might remain uninsured, relying on his dad to pay the doctors and Abbott Laboratories to give him the test strips.

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Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR's healthcare desk, which is part of our United States Project on the coverage of politics and policy. She also blogs for Health News Review. Follow her on Twitter @Trudy_Lieberman.