How the Candidates' Health Care Plans Would Affect Real People

Election '08
This is the fifth in a series examining how the candidates' health care proposals will affect ordinary people who live in the river town of Helena-West Helena, Arkansas, and how the press could cover that angle. Part I is archived here, and parts II, III, and IV are archived here, here, and here.

Michelle Hernandez, age thirty-seven, hasn't had it easy. She grew up in Chicago and lived with her grandmother before moving to New Jersey to stay with other relatives. She eventually ended up in the South, where she and her four children now live with her kids' grandmother.

Her unstable life has also left her with unstable health care. She was first diagnosed with diabetes when she was pregnant with her daughter Jasmine, now seventeen. Five months ago, Jasmine was also diagnosed with the disease, which disproportionately affects Hispanics in the U.S. The Centers for Disease Control and Prevention reports that Hispanics are three times more likely than Caucasians to contract diabetes between the ages of eighteen and forty-four. Hernandez and her daughter are among those affected.

"I'm not feeling too well right now. I feel very weak," she says. "I'm not eating the right way." She often neglects breakfast and, when she is not working, boils an egg or a hot dog for lunch. Money for good food is scarce, and the local food bank tightly rations its stock.

Hernandez works three days per week making sandwiches at Subway. (She used to work a five-day week, but her health problems interfered.) She brings home $117 per week, which is spent on gasoline for her 1993 Chevy Blazer, a storage unit for her belongings, rent to her kids' grandmother, and food. Subway gives her no health insurance, and offers no workplace initiatives to help employees with chronic conditions like diabetes.

So Hernandez is uninsured. She cannot afford to buy a policy in the commercial market even if she could qualify, which she couldn't. Arkansas Medicaid won't take her either. She doesn't fit any of the eligibility categories. Medicaid officials have said that she might qualify under the "medically needy" program, but first she has to spend a large part of her income on medical care. But, she says, she doesn't have seventy-five dollars to pay for doctors' visits, even though she needs a check-up and an eye exam. Retinal exams, the standard of care for diabetics, are out of the question. "I can't see through these glasses," Hernandez says.

She finds herself in the classic Medicaid dilemma. She needs medical bills to qualify for Medicaid, but has no money to pay doctors in order to accumulate those bills. She has often gone without her medicines -- for a thyroid problem and her diabetes -- because they are unaffordable. Although a drug company assistance program periodically supplies insulin, the lack of proper, continuing care for her disease is taking its toll.

While all of her children currently qualify for Medicaid, Jasmine, the oldest, will "age" off Medicaid when she turns eighteen in December. She, too, will be uninsured with no way to treat her diabetes. Aging off health insurance is also a problem faced by children of wealthier parents. Indeed, some thirteen million young adults between ages nineteen and twenty-nine have no coverage. But for poor kids pushed off of Medicaid, the consequences can be particularly severe, since there usually isn't much extra money around to help them buy a policy.

Hernandez worries about Jasmine. She wants to be a radiology nurse someday, but her mom fears she may have to drop out of the community college she currently attends and find a job that offers health insurance. Says Hernandez: "She's going to go through all the same things I'm going through." That is, unless health reform somehow manages to address the plight of young adults forced off Medicaid.

How they would do under John McCain's plan

McCain's proposals, which embrace a laissez faire health insurance market, would do little for Hernandez and her daughter. His proposed tax credits wouldn't help them buy insurance, because no health insurer would be crazy enough to assume the cost of their medical bills. Diabetes simply disqualifies them. Nor will McCain's guaranteed assistance plan be of much help, unless they receive huge federal subsidies to pay for the coverage -- something on the order of 100 percent of a policy's cost. If the subsidies won't cover the entire cost, which seems likely given the growing federal deficits, it's hard to see how they could pay the premiums for such a plan.

McCain talks the talk about "coordinated care," with providers cheerfully collaborating to produce the best health care. Such coordination, suitable for diabetics who may need to see different doctors, holds the promise of offering better outcomes at lower cost for the country as a whole. McCain also promises to dedicate more federal research to curing chronic disease. Well, yes, fine, but Michelle Hernandez needs help right away or else her disease will get worse. Promises of more money for research do not help her now. Ditto for McCain's call for health information technology and electronic medical records. None of this means much to Hernandez, who doesn't even have a regular doctor. Until she gets a ticket to see a physician, she has no care to coordinate, no treatment to document in an electronic record.

How they would do under Barack Obama's plan

Obama's plan emphasizes a "public-private partnership." Clearly, Hernandez and her daughter are not candidates for the private part. Because they are poor, Hernandez and her daughter might fare decently in a greatly expanded public system that would help them pay for the medical care. Such a plan would have to keep children on Medicaid longer and expand the categories for eligibility so that Hernandez could qualify. In other words, if they had the option of going into a truly public system -- a "Medicare for all" arrangement -- Hernandez and her daughter would benefit.

But if an Obama plan relied on the purchase of coverage from private insurers and did not require them to cover diabetics, they would be as neglected as they'd be under McCain's proposal. In either case, they would need help paying for the coverage. How much money Congress is willing to spend on subsidies for those with low -- even very low -- incomes is the great unknown.

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