Missing Persons Redux

Insuring those at the very bottom

Last Monday night, the NewsHour with Jim Lehrer devoted air time to an exchange between two former secretaries of Health and Human Services—Donna Shalala, who served in the Clinton cabinet, and Michael Leavitt, who served under George W. Bush. One of Leavitt’s comments was particularly striking:

This debate started out about 50 million people who didn’t have insurance. It’s now become about the 250 million who do and the things that will occur to their insurance when we essentially put the entire system under the guidance of the federal government and increase the cost to everyone. The debate has shifted away from just how do we care for those who don’t have insurance to the impact that this law could have on those who do?

It’s a point that the media, for the most part, have missed. Health reform coverage has mostly revolved around what the president and other pols have been saying, and they’ve spent a lot of time promising that the price of coverage will come down—a proposition experts believe at best is debatable—and that insurance reforms will make the big bad insurance companies behave themselves—perhaps another debatable point. What they haven’t talked much about are the health care needs of the poor. Not surprising, I guess, since middle class folks with insurance vote; those begging in the subway don’t.

Which brings me to a subway incident the other day, which suggested another group of missing persons the press has yet to write about—those at the very bottom of the income ladder. A crippled man, legs bowed out, his bent arms clutching to walking sticks, fought to open the heavy door that separates the subway cars—a difficult task even for those whose body works. “Can someone please help me open the door,” he cried out. No one at his end of the car got up to help—not even the tall young fellow standing next to the door, apparently so absorbed with sounds from his iPod that he couldn’t lend a hand.

The man was thin and gaunt, and pleaded for food. “Can someone give me some food,” be begged. He was hungry, and his shaky hand held an empty carton that once contained Tropicana orange juice—his tin cup. I thrust a few dollars into the carton, and he held out his wrinkled hand in thanks.

I saw this man’s predicament in terms of the health care debate and the point Leavitt made on the NewsHour. Where does this man fit in? Or does he? Even if Medicaid—about to expand under reform—catches him and offers a medical olive branch, what about the other things which make a person healthy? Like housing, money for food, and nutritious food itself. If you don’t have good nutrition, you don’t have good health—a point that has surfaced in the debate only as it relates to obesity and the amount that obesity-related illnesses will cost the health care system down the road. Damn those fat people!

Interest groups have linked illness prevention to obesity, playing the blame-the-victim game. But what about the thin man in the subway who is possibly starving? Millions more are like him. What were his health problems? Who was connecting him to services?Where are the reporters who are trained to connect all these dots? Who so far in the health debate has shown the courage to do what’s right for everyone? And what was it that kept New Yorkers in the subway car from holding a door open for a crippled old man?

Some questions to ponder on the day before Thanksgiving.

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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.