Health Care on the Mississippi, Part IX

Real people and the candidates’ plans

This is the ninth and final entry in a series that has examined how seven people who live in the town of Helena-West Helena, Arkansas, would fare under the health proposals offered by John McCain and Barack Obama. The entire series is archived here.

The policy wonks have begun their hand-wringing. “If the country’s finances get too depleted, both parties could lose their zeal to retool the health care system,” John Holahan, director of health policy for the Urban Institute, told the Des Moines Register. In a Chicago Tribune op-ed last Sunday, noted bioethicist Ezekiel Emanuel conceded that “the financial crisis has appeared to knock health care off the national agenda,” while arguing that the crisis might make reform more politically feasible, and even necessary for financial stability. A few weeks ago on NBC’s Today, Barack Obama said that the financial bailout means that he cannot immediately accomplish everything that he has proposed during the campaign: “I think we’re going to have to phase it in. And a lot of it’s going to depend on what our tax revenues look like.”

Okay, so the county’s financial problems might have deflated the momentum that was building earlier for health care reform. Apparently, the government doesn’t have money to help both the big, bad businesses that got into trouble and the little people who can’t pay for health insurance. In other words, the billions needed for subsidies to help people buy private health insurance have been put to other uses. There are also stirrings that maybe we shouldn’t be helping people who don’t have insurance anyway. The reasoning goes like this: It’s their own fault if they smoked and got cancer or ate too much and got diabetes. For awhile, it looked like the country was beginning to agree that everyone is entitled to health care. Even the American Medical Association and the insurance industry have even come around to that idea. In last week’s debate, Barack Obama affirmed that health care is a right; John McCain did not, saying instead that health care was a responsibility. Whose responsibility, he didn’t quite make clear.

Now along comes Robert Samuelson, columnist at The Washington Post and contributing editor at Newsweek, challenging the notion of health care as a right. Samuelson argues that casting medical care as a simple right ignores questions of how far that right should extend, and how its fulfillment might compromise other rights and needs. He contends that personal habits, genetic makeup, and age make people healthy or unhealthy, and adds:

The crying need now is not to insure all the uninsured. This would be expensive {an additional $123 billion a year, estimates the Kaiser (Kaiser Family Foundation) study} and would provide modest health gains at best. Two-fifths of the uninsured are young (19 to 34) and relatively healthy.

As I read Samuelson’s piece, I thought of the people whose stories we have told on the Campaign Desk. Which ones don’t have a right to have health care? Who is more deserving of medical treatment? The 43-year-old with symptoms of uncontrolled diabetes because he can’t pay for care? The disabled woman whose $758 monthly income from Social Security disability is too high to qualify for Arkansas Medicaid? The farmer who has no coverage for his urinary problems? The insurance agent’s son who suffered a concussion playing football?

Superficial describes this year’s health care discussion. There has been a lot of talk about getting insurance into everyone’s hands, but little conversation about equity and poverty. In fact, it seems the candidates have aimed their health care comments toward the middle class. Except for a few “blame-the-victim comments” like Samuelson’s, there hasn’t been much said about the larger causes of poor health: like stress from being unable to pay your bills, or jobs affording little down time, or bad housing, or the chemicals sprayed on cotton. Almost everyone I interviewed in Arkansas—black or white, rich or poor—at one time or another in their lives picked cotton. “Health Care on the Mississippi” indicates a universal need for medical treatment. But despite the campaign rhetoric, the candidates’ proposals will get us neither universal care nor universal insurance to pay for it.

More of the people I interviewed would benefit more from Obama’s proposals than those of John McCain. They are older, sicker, with lower incomes—the very people who will have trouble getting coverage under a McCain plan, according to a Lewin Group study released last week. Some people with the lowest incomes, like James Bell IV and Michelle Hernandez, might get coverage from an Obama public insurance option if government helped pay for the coverage and if the government provided the benefits. But if an Obama public program option calls on commercial insurers to provide the benefits, and if they are not forced to take people with diabetes, then people like Bell and Hernandez will remain uninsured.

Obama’s plan would expand current public health programs. But if the government has no money to improve coverage under Medicaid—which might allow Hernandez’s daughter, Jasmine, to continue her insurance when she turns eighteen in a few months—or if it can’t afford to let the disabled Annette Murph get on Medicare without waiting two years for the opportunity, then these people, too, would continue to be uninsured. James Bell III and Kevin Smith have employer coverage, which means they will have to come up with extra money to pay income taxes on those benefits, as McCain has proposed. Neither would benefit from his tax credit, because they have preexisting health conditions that disqualify them from coverage and couldn’t buy insurance on their own. Smith, Pam Culp, and Glenn Hall would continue to be underinsured under either plan. Their incomes are high, and they wouldn’t qualify for any subsidies to help them buy insurance. Most likely they would keep what they have—insurance with high copayments, high deductibles, and, in Hall’s case, an exclusion from coverage of his existing health conditions. (Under Obama, insurance companies might be prohibited from adding such exclusions.) And they’d pay a pretty penny for the coverage they do get.

We have repeatedly urged the media to find people in their communities and tell their stories through the lens of the candidates’ proposals. News outlets that have done that are few and far between, which may be one reason why a recent poll by the Harvard School of Public Health and Harris Interactive found that average people don’t see much difference between the two plans, and don’t know how the plans would affect them personally. As we move toward a new administration with health care maybe somewhere on the agenda, it’s not too late for the media to put the new president’s health proposals to the test.

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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.