Murph turned to Medicaid’s program for the medically needy—less than ideal for someone who needs regular care. Every three months she must re-qualify for coverage. If she doesn’t qualify again, she pays her bills out of pocket. But even for this program, she must “spend down,” or carry medical bills roughly equal to three months of her income. Although she can use older bills to qualify, Medicaid won’t cover those; it does pay for medical care she needs during the three-month eligibility period. She has applied to the program three times; once she got coverage; once she didn’t. She is awaiting word on her third application. The strict rules save money for Medicaid, but they don’t help people like Murph get continuous care.

How she would fare under the candidates’ plans

Candidates are not talking about the people who fall through the gaps in the public safety net. Disabled people are the health system’s step-children, and will continue to be under either McCain or Obama. Since neither plan offers truly universal health coverage that would be extended to all citizens as a matter of right, the disabled will still need Medicare and Medicaid, and will still have to endure their gaps in coverage and in care. About 2.5 million people are expected to apply for Social Security disability insurance this year, many of whom will be turned down. The number of applicants will continue to rise, putting more financial pressure on the public programs. This crisis-to-be has barely been discussed.

Under McCain’s plan

McCain’s $2500 tax credit to buy a policy wouldn’t do Murph much good: she lacks the money to pay for the rest of the premium, and she wouldn’t qualify anyway. No carrier would take her on. She wouldn’t qualify for his still-vague guaranteed access plan, but it probably wouldn’t help her either. She would be unable to pay the inevitably high premiums, and she wouldn’t qualify for subsidies since she already qualifies for Medicare and Medicaid. Getting benefits from those programs often disqualifies people from state high risk pools, and the McCain proposal might work the same way. In sum, his plan wouldn’t hurt her but it wouldn’t help much, either.

Under Obama’s plan

Obama and his surrogates have pushed a strategy that builds on the preexisting “public-private partnership”—citizens can get coverage from an employer, buy their own, or go to a public program. Murph is already in the public part, which would probably make her ineligible for his proposed public program for people without access to employer coverage or other public programs. Yesterday, at a town hall meeting in Albuquerque, he said that people “need relief now.” “So my attitude is let’s build up the system we got. Let’s make it more efficient…”

Most likely, Murph and her disabled-and-waiting counterparts won’t get much relief. Obama calls for expanding Medicaid, a move that could help her get continuous benefits while avoiding the onerous “spend down” process. But an expansion would take lots of money from both the federal and state governments, and state Medicaid budgets are perennially tight. The test of Obama’s commitment to greater coverage will come in the expansion of federal programs, while maybe even compressing the waiting period for Medicare for those getting Social Security disability payments. If the public programs don’t expand to catch more people or make things easier for those already enrolled, those like Annette Murph will still be in the same fix.

Trudy Lieberman is a fellow at the Center for Advancing Health and 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. Follow her on Twitter @Trudy_Lieberman.