For a time during the presidential primary season, it looked as if health care was going to be the dominant issue of the campaign. Over the past few months, however, the topic has seemed to drop off the radar screen.

"We all did think health care was going to be at least the No. 2 issue (after the Iraq war)," said Mimi Collins, chief executive officer of the Longstreet Clinic in Gainesville. "Now everyone's talking about the economy.

But they don't realize that health care is part of the economy, too."

There are still an estimated 47 million Americans who don't have health insurance, including about 21,000 in Hall County. There's probably an even greater number of people who are underinsured, who have high deductibles or such meager benefits that it's almost like having no coverage at all.

"Even if you have Medicare, it's unbelievable the out-of-pocket expenses you have to pay," said Brenda Dalin, community services director for Ninth District Opportunity, a Gainesville agency that assists low-income residents.

Dalin said people who have no insurance are a drain on the health care system.

"There's no preventive care," she said. "People wait until they're really sick, and then it costs a lot more to treat them."

Dalin believes politicians should give serious consideration to a single-payer, government-run health care system, similar to those in Canada, England and most other developed nations.

"I think we need to look at how other countries have solved this problem," she said. "I think more government resources need to be poured into it, like the ‘war on poverty' that (President) Kennedy started."

Such an idea might be political suicide right now, with the United States' economy spiraling toward crisis. Neither of the mainstream presidential candidates, Republican John McCain and Democrat Barack Obama, have proposed a change that drastic.

But there are distinct differences between the health plans they're offering. McCain's would tax insurance premiums paid by employers and would provide incentives for people to purchase individual insurance plans.

Obama has proposed a "National Health Plan" for people who don't have employer-sponsored insurance and aren't eligible for existing government programs such as Medicare and Medicaid.

Independent studies of the two plans, released last week, concluded that Obama's proposal would cost too much and McCain's would fail to cover enough people.

Those results aren't surprising to Cheryl Christian, director of Good News Clinics, which provides free care to the poor in Hall County.

"I haven't seen anything that seems to be the magic answer," she said. "As a country, we really have to address making insurance accessible, affordable and portable. People who have health issues are in essence uninsurable unless they can get it through their employers."

But the employer-based system breaks down when the economy goes sour. "We're seeing more people coming in here (at Good News) looking for help because they've lost their jobs and their insurance," Christian said.

Good News has been praised as a model for free clinics throughout Georgia. But it relies on volunteers and donations, and can't serve all of the people who need help. To qualify, patients must have extremely low incomes and no access to any form of health insurance, and they must be residents of Hall County.

Hall has several other programs, such as the Health Access Initiative, that help provide care to the working poor. But as laudable as these projects are, they can only make a small dent in the problem.

Keeta Wilborn, chair of the nursing department at Brenau University, said local agencies can't do it alone. She thinks some action is needed on the national level.

"There are so many people who have no care at all, and that affects all of us," she said. "I think it's a crucial issue that both parties need to be talking about seriously. You can't focus on the economy without focusing on health care."

Deb Bailey, director of government affairs for Northeast Georgia Health System, said if the economy deteriorates further, it could make a difficult situation worse.

Reimbursement from Medicare and Medicaid, which hospitals and doctors say is already inadequate, could shrink even more in the future.

"It's clear that funding health care is going to be more of a challenge, given what's going on at the state and federal level," Bailey said.

Voters: Health care is important
Wilborn said she plans to watch the presidential debates and hopes the candidates will offer more details about their health care proposals.

She also said health care will be one of the deciding issues when she chooses a candidate. "I look not just at their words but at what they've done in the past (in terms of their voting record)," she said.

Christine Smith, who lives in Forsyth County just across the Hall line, said she, too, will be basing her vote partly on health care policy.

"I would like to hear something concrete from candidates about what they're going to do," she said.

For Smith, it's a personal issue. She's struggling to get by on small monthly payments from Social Security and a part-time job that has no benefits.

"I've called all over trying to find free or low-cost care," she said.

But Smith is one of those people caught in the middle: unable to afford decent insurance coverage, but with too much income to qualify for assistance programs.

"I want insurance like the members of Congress get," she said. "I think our health care system is better than (those in) a lot of countries, but it needs work."

Recently, the private sector has begun helping out people like Smith in a way that government can't or won't.

"Thank goodness for Wal-Mart's $4 (generic) prescriptions," said Smith. "At least now I can get my blood pressure medicine. The problem is being able to go to a doctor to get the prescription written."

Physicians' group opposes government-run system
David Cook, executive director of the Medical Association of Georgia, thinks improving access to doctors could help cut costs.

"You can cover everyone, but if there's no doctor for them to see, the insurance isn't worth much," he said.
"We need to do more to incentivize doctors to go into primary care."

Cook said medical students don't want to become primary care physicians anymore because the reimbursement is so low they can't pay off their medical school debt.

He believes primary care physicians save the system money because they have the judgment to know when a patient really needs to be referred to a specialist.

The Medical Association of Georgia has not endorsed either of the presidential candidates. Cook said neither McCain nor Obama would do enough to cut costs. He also thinks Obama's plan is "quasi-governmental."

"We are looking for candidates that have market-driven policies," he said. "We are very much against a single-payer plan. We need a private-sector solution."

Cook said MAG is not opposed to a mandatory policy that would require every person to buy health insurance just as drivers are required to have car insurance. "We would support universal coverage, but not through a single-payer system," he said.

Preventing illness could save money
Dr. Jack Chapman, a Gainesville ophthalmologist who is currently serving as MAG's president, wants a system that would dissolve the link between health care and employment.

"We should go toward a plan that is individual-based rather than employer-based," he said.

The obvious advantage is that people would still have insurance coverage even if they changed jobs. But there could be other benefits, Chapman said.

"There's prevention and wellness care in the pediatric population, because we've seen how well that works," he said. "That needs to be done in the rest of the population. But employer-based plans have no incentive to offer wellness benefits, because employers tend to switch plans every year."

Of course, doctors want to see higher reimbursements from the two federal programs, Medicare and Medicaid. But Chapman wonders whether something also could be done to control bureaucracy in private insurance companies.

"I've heard that as much as 31 percent of health care cost is administrative," he said. "They spend so much time getting prior approvals (for treatment) and denying claims. About 95 percent of the time, these things (eventually) get approved, and the delay just costs more money."

But Wilborn said while reforming the insurance industry is important, she wants the health care system to focus more keeping people from getting sick in the first place.

"It's much cheaper to prevent something than to cure it," she said.