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Poor Plans for Healthcare

Neither Kerry nor Bush's healthcare plans would have done much for the uninsured poor.
The Nation

Deep in the heart of Texas, not far from the Alamo, another battle is
being waged. It's a fight against all the illnesses associated with
poverty in America's inner cities--in this case San Antonio. Here, in
poor neighborhoods where chain-link fences surround ramshackle
bungalows and billboards proclaim We Buy Ugly Houses, half of all
births are to girls younger than 18, many of whom receive late
prenatal care. Infant mortality has increased by 49 percent since
2000 in Bexar County, in which San Antonio is located, and one-third
of those deaths occur in nine of the city's seventy-two ZIP codes.
Diabetes is rampart, along with obesity; in some areas more than half
of the children between 2 and 4 who come to USDA-sponsored clinics
are overweight. One-quarter of San Antonio's population--about
360,000 residents--have no health insurance. The median income of
$26,800 in the nine ZIP codes barely covers housing and
transportation, let alone an insurance policy or nutritious food that
could forestall major illnesses.

Medical care here mirrors everything that is wrong with the US health
system, especially for its poorest citizens. But neither the
proposals of Senator John Kerry nor those of President George W. Bush
would do much to change it. While Kerry's plans would do more than
Bush's to assist the poor and those without medical insurance, both
candidates' proposals focus on small changes instead of calling for
the wholesale rethinking that is urgently needed.

San Antonio is a good place to see the current system's many
shortcomings. For a start, neither candidate's proposals root out the
system's perverse monetary incentives that spur a new kind of white
flight from poor neighborhoods. In San Antonio, practitioners and
specialty clinics continue to move north near the gated communities
in the Texas hills, chasing reimbursement dollars from wealthier
patients, who have insurance. Entrepreneurial doctors who build their
own surgical centers siphon off services located in facilities
serving the poor, like the lucrative outpatient orthopedic procedures
at San Antonio's Christus Santa Rosa, leaving the hospital with fewer
dollars to care for the uninsured.

More significantly, neither candidate's proposals would control the
relentlessly rising costs of new technology. Bush would encourage
people to use health savings accounts, which make consumers pay more
of their medical bills, and he would cap malpractice awards; Kerry
would give taxpayer money to businesses to help them cover expensive
medical claims in the hope that the premiums they pay for their
workers might thereby come down; in return, the businesses would
have to insure all their workers. But even if these approaches save
a few dollars for doctors and big corporations, they do nothing to
slow the cost of new drugs, treatments and machines, the major cause
of healthcare inflation. Kerry does want the government to negotiate
drug discounts for Medicare beneficiaries, a small step toward
eventually imposing price controls on pharmaceuticals. But the plans
include no mandates, no requirements, no enforcement teeth. Doctors'
incomes would be safe; employers wouldn't need to provide coverage;
insurers could still profit from selling policies; and drug
companies could still reap a return that's the envy of every
industry in the world.

That neither proposal has sparked a backlash from these special
interests--the same ones that created a firestorm for the Clintons a
decade ago--says something about how empty the plans really are.
Instead, the proposals would attempt to make some of the nation's
poorest people and some of the most marginal businesses foot the bill
for health coverage, offering the prospect of tax credits as bait.
Bush's less generous plan would give a credit of up to $2,000 plus a
$1,000 contribution to a health savings account to families with
incomes lower than $25,000. Kerry's plan would give a 25 percent
credit to individuals not quite eligible for Medicare if their
incomes fell below $28,719. He would also give a 75 percent credit to
people between jobs, and a credit of up to 50 percent to small
businesses that agree to pay half the insurance premiums for their
low-income employees. According to Dr. Michael Chernew, a health
policy expert at the University of Michigan's School of Public
Health, neither approach is likely to make much of a dent in the
number of the uninsured. "The evidence suggests that subsidizing
insurance premiums will be a relatively expensive way to encourage
coverage, and relatively few people would respond," Chernew says.

He means people like Norma and Allen Samford, who are trying to make
a go of a small shop selling flowers and piñatas near the San
Fernando Cemetery, in one of San Antonio's poorest areas. Competition
is fierce, with four other flower sellers and three other
piñata sellers in the neighborhood. The shop grosses $3,000 in
a good month. When I mentioned tax credits to Norma, she replied that
health insurance ranks low on their priority list. Other bills come
first, including $225 a month she is paying to the hospital where her
son Dominic was born five months ago. Even if the Samfords decided to
try to take advantage of the credits, they might fall through the
cracks, as many people do with such incremental approaches. They earn
too much for Bush's plan; they're too young for Kerry's. They might
be eligible for Kerry's small-business credit, but with insurance
policies running upwards of $10,000 a year, it's unlikely they would
have the money to pay the premium that triggers the credit.

For those who can't buy insurance, Bush and Kerry have an answer:
Enlarge the network of community clinics in low-income neighborhoods
using government money. Kerry wants to give extra funds for capital
improvements so the clinics can serve more people, while Bush wants
to make sure that every poor county has one clinic. But it's doubtful
that either administration would provide enough money to fill the
vast need in places like inner-city San Antonio. At Barrio
Comprehensive Family Health Care Center, the waiting time for dental
services is six weeks. For specialty care or surgery, clinic staff
must cajole doctors and hospitals in the area to examine their
patients pro bono and donate operating-room time. Pregnant women are
able to get basic prenatal services, but if complications develop,
it's a struggle to pay for such things as sonograms and medicines.
"So many times I find myself trying to weave through the funding
stream so they can pay for lab work," says Dr. Susan Crockett, an
obstetrician who works in community medicine in San Antonio.

Both Bush and Kerry say they want to expand the Children's Health
Insurance Plan, or CHIP, and Medicaid. The problem here is that
state legislators control part of the purse. To placate them, Kerry
wants the federal treasury to pay all the costs of covering kids
under Medicaid if the states agree to cover healthcare for very poor
families and childless adults. Bush's "Cover the Kids" campaign
would give $1 billion to the states to enroll more children in CHIP
and Medicaid. But even with federal handouts, these programs remain
at the mercy of the states, which often act like Jack the Ripper
when budgets are tight. Last year the Texas legislature slashed
funding for CHIP, with the goal of reducing the number of kids
getting healthcare. The legislators have succeeded: In May 2002,
529,000 children were enrolled; by this past September the number
had dropped to 356,000. So far, the state has kicked almost 9,000
children in Bexar County off the CHIP rolls. Those who remain no
longer receive dental and vision care. Children with cancer can't go
to a hospice to die.

Every six months families must prove all over again they are
sufficiently poor to qualify for the programs. And if they have more
than $5,000 in assets, including the value of a car over $15,000,
their children are ineligible. Imagine a middle-class family giving
up the family car so their kids can get vaccinations and
back-to-school checkups. Premiums have also increased from $15 a year
to $15 a month. Some 70,000 families were in arrears this past June
when the state sent notices warning that if the premiums weren't
paid, their children might lose coverage. After a public outcry, the
state declared in September that it was suspending premium collection
for an indefinite period.

Real healthcare reform would, of course, mean more than just
additional clinics or expanded state or federal programs. Even if
universal health insurance magically appeared tomorrow, it would only
get us one-third of the way toward improving health, says Dr.
Fernando Guerra, San Antonio's health director. "Other things affect
people in more profound ways than just getting in to see a doctor,"
he says, citing behavioral, environmental, social and economic
factors. But the candidates' proposals don't even get us to the
one-third marker. Other countries have shown that they can
successfully insure everyone, but here, universal health insurance is
off the table. They have also had the guts to control costs, which is
why Canadian drugs are so much cheaper. In America, however,
healthcare, once provided as a social mission, has become a commodity
increasingly available only to those who can pay. Neither Bush nor
Kerry is talking about that.

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How Long ago Was This Written? 05.Nov.2004 20:43


What Kerry would do is beside the point right now. This article is out of date.