When Rudolph W. Giuliani was diagnosed with prostate cancer in the spring of 2000, one thing he did not have to worry about was a lack of medical insurance.
Today, the former New York mayor joins two other cancer survivors in seeking the Republican presidential nomination: Arizona Sen. John McCain has been treated for melanoma, the most serious type of skin malignancy, and former Tennessee Sen. Fred Thompson had lymphoma, a cancer of the immune system.
All three have offered proposals with the stated aim of helping the 47 million people in the U.S. who have no health insurance, including those with preexisting medical conditions.
But under the plans all three have put forward, cancer survivors such as themselves could not be sure of getting coverage -- especially if they were not already covered by a government or job-related plan and had to seek insurance as individuals.
"Unless it's in a state that has very strong consumer protections, they would likely be denied coverage," said economist Paul Fronstin of the Employee Benefit Research Institute, who has reviewed the candidates' proposals. "People with preexisting conditions would not be able to get coverage or would not be able to afford it."
If the arguments against the Democratic presidential candidates' healthcare plans include higher taxes and greater government involvement, then the Achilles' heel of the GOP plans is their dependence on the private market, which often rejects applicants with health problems.
Republicans want to expand the existing private insurance system, offering new tax breaks as a way of helping people buy insurance individually. But they also want to avoid federal regulation that would tell insurers whom they have to cover and how much they may charge.
That means the self-employed and others seeking individual coverage would be subject to a marketplace in which insurers generally pick the healthiest applicants and turn the rest away. Cancer survivors -- even if they have been free of disease for several years -- are routinely denied health insurance when they try to purchase it as individuals.
Even if coverage is offered, it often comes with restrictions or high premiums that many find unaffordable.
In the individual market, coverage rules "are really quite fussy," said Karen Pollitz, a Georgetown University research professor who specializes in the field. "Most companies won't touch you if you have a cancer history within five years, and with some companies . . . if you've ever had cancer, you can't get coverage."
Pollitz surveyed 22 companies to see whether they would cover a hypothetical breast cancer survivor five years after she was successfully treated. Eleven companies said they would deny coverage, and six said they would issue a policy at standard rates. One company said it would charge double the usual premium. Another said it would issue a policy but exclude future cancer treatment. Three insurers did not respond.
Susan Brown, 53, discovered her melanoma early -- a sore spot on her left shoulder smaller than a pencil eraser. She was successfully treated in 2000. But Brown, who lives in a small town in East Texas, had to give up her job as a medical office manager -- and the healthcare benefits it came with.
Since then, she said, she has been unable to find private coverage that she can afford. One company turned her down. Another wanted a letter from her cancer specialist stating that the disease would not return. Others demanded premiums that would have drained her bank account in return for policies that still would not have covered a recurrence of cancer.
The candidates "can't sit there and say they understand what people are going through, because they've got healthcare," Brown said. "We went through the same illness, however [they] don't understand what it's like not to have health insurance."
Brown remains cancer-free but uninsured. She depends on charity care for her follow-up cancer screenings, she said.
The campaigns say they are still fleshing out their healthcare proposals.
A Giuliani advisor says the former mayor's campaign is aware of the coverage problem and debating how to address it.
McCain, who has offered the most detailed plan, has made a commitment to improve coverage for the sickest people by working with the states, and he has outlined some ideas he would try to carry out.
Thompson's plan is a broad sketch at this point, and an advisor said specific options on coverage remained in development.
Experts say the Republicans' approach to improving healthcare, which focuses on the use of federal tax breaks to help individuals and families afford insurance on the private market, does not acknowledge the problem people in less-than-perfect health have finding health coverage.
"When you give a [tax credit] to somebody, that can be a help," said Stuart Butler of the conservative Heritage Foundation. "But if they have a history of severe medical problems, giving them $5,000 doesn't really help them to afford insurance. Unless you build in some kind of risk-spreading mechanism to the equation, a subsidy doesn't cut it."
One of the reasons the individual market can be hostile territory for consumers is that it consists of a relatively small pool of people in which to spread risks.
About 17 million people younger than 65 are covered by individually purchased health insurance, about one-tenth as many as the 164 million covered under employer plans, census figures indicate.
And because the market is organized along state lines, the risk pool can be even smaller. Moreover, each state has different rules, and only a few require insurers to guarantee coverage or limit premiums. People in employer and government plans, by contrast, enjoy legal protections that prevent the sick from being excluded or charged more.
An expert with access to a manual that insurers use to make coverage decisions said that most companies wouldn't consider a cancer survivor for 10 years, with some exceptions, and then would only issue a policy at a higher premium.
For example, a person treated for a small, localized melanoma could be covered after five years at a higher premium. But if the tumor were larger or deeper, that person would have to wait 10 years. For prostate cancer, a man with a less severe form of the disease could be covered after five years of being cancer-free, at a 40% higher premium. The expert asked not to be identified, citing business reasons.
Insurers say the harsh realities of healthcare costs don't give them better options.
Although most consumers might not realize it, a small proportion of patients accounts for a large share of health costs. In 2001, for example, the sickest 10% of insured patients accounted for 60% of total costs, according to an analysis by healthcare consultant Mark Merlis.
Insurers say the only way to keep premiums affordable on the individual market is to screen out the costliest cases.
The Democratic presidential candidates would address the problem by requiring insurers to guarantee coverage, and by limiting or subsidizing premiums. But Republicans are leery of taking such a direct role in the market.
Douglas Holtz-Eakin, an advisor to McCain, said the senator would work with the states to use some Medicaid funds to subsidize health insurance for people in poor health. Medicaid is a federal-state program that covers the poor and also provides funding for hospitals that take care of large numbers of uninsured patients.
McCain "wouldn't simply say, 'Hey, here's a tax credit -- go have fun,' " Holtz-Eakin added.
Giuliani advisor Donald Moran said the former mayor recognized that "the existing structure of the individual market is really not a viable alternative" and that the campaign was actively considering various options.
One possibility would be to allow insurers to sell individual policies nationally instead of state by state. But many consumer advocates say that would undermine hard-won protections in the few states that have them.
But without a convincing solution to the problem of healthcare security, the eventual Republican nominee's plan could fall flat with voters in the general election.
"People who advocate the individual market have a lot of work to do to explain how they are going to get better results than we get today," said Paul Ginsburg, president of the Center for Studying Health System Change, a health policy research group. "One of the ironies is that that takes regulation by government, and Republicans running in the primaries don't like to talk about that."
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