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.