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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