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Which Candidate's Health Plan Would Do the Most for Ordinary Americans?

Neither candidate is talking much about the people who fall through gaps in our public safety net. And neither plan is truly universal.
 
 
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This is the third in a series examining how the candidates' health care proposals will affect ordinary people who live in Helena, Arkansas, and how the press could cover that angle. Part I is archived here, and Part II is here.

Annette Murph

Annette Murph, age 54, finds herself in a classic bind: medical problems prevent her from working. When they can't work, disabled people lose health insurance from their jobs and seek help from public programs, often enduring long waiting periods and a lot of red tape. What irony! The American way of health care forces those with serious medical problems to battle an inhospitable system that, at times, seems designed to keep them from getting care rather than meeting their medical needs.

Healthwise, Murph has been unlucky. She got high blood pressure and arthritis when she was 28 -- from her mother and grandmother, she says. Nine years ago, doctors diagnosed diabetes -- her parents, cousins, and uncles all had the disease. Her thyroid gland is abnormal, and she has had two heart attacks; two first cousins died young from heart attacks. Two years ago she underwent knee replacement surgery, after which she could no longer work as a buffet attendant at one of the casinos that line the Mississippi River not far from her home.

As a kid she picked and hoed cotton, as did so many in the Delta, and then repackaged pesticides and herbicides for a local chemical company. Until her knee surgery, Murph had worked at the casino for twelve years and had health insurance that covered her heart attacks. It also allowed her to regularly see her cardiologist and internist, who checked her thyroid and monitored her diabetes. After the surgery, her knee would no longer bend; it continues to hurt and swell, making it impossible to stand for long periods or move about easily. She could hardly work as a buffet attendant. The unsuccessful surgery, plus her other ailments, qualified her for Social Security disability payments.

After a remarkably short five-month period (the wait averages around two and a half years), she got her first monthly check of $758. That check, and thirty-seven dollars worth of food stamps is her entire income. More than one-third goes for rent on her tiny house, its living room decorated with pictures of relatives and Dr. Martin Luther King. She has little left for food, gasoline to power her nine-year old car, utility bills, and prescription drugs (she takes fourteen). Sometimes she gets help from drug company prescription assistance plans. If she can't, she goes without.

Right now she is without one of her four blood pressure medicines and one of her four diabetes medications. Without the diabetes medicine, her blood sugars rise into the 300 range -- too high. Since she left her job, she has accumulated over $15,000 in unpaid medical bills. Half were for care she needed from the local hospital in 2007; half reflect the care she needed this spring from cardiologists in Little Rock. On her income, she cannot pay them. "This is really frustrating. I'm not supposed to be upset because of my heart condition," Murph says. "I'm trying to stay calm, but I can't because of this system."

The system to which she refers is Medicare and Medicaid, believed by most people to be a safety net for the millions of Americans who become disabled, many by the time they turn fifty. Sometimes, the net is riddled with holes. "I thought when you are disabled, you automatically get covered," Murph says. "I've never been on government assistance before since I have always worked. When I couldn't go back to work is when this nightmare started."

Although Social Security disability payments qualify her for Medicare, there is a two-year wait for coverage, and she still has six months to go. She couldn't get continuous coverage under Medicaid because her $758 monthly income is too high . In Arkansas, a single person can make no more than $108.33 a month to qualify for that program.

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.

 
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