Survivors of Hurricane Katrina who have evacuated their home states and are suffering from health problems and financial distress have yet another serious problem: They're often categorically ineligible for Medicaid benefits. One in every five people seeking Medicaid coverage at hurricane shelters has been "screened out" of applying, and one third of processed Medicaid applications from these shelters have been denied coverage.

As a result, a recent survey by the Kaiser Family Foundation and Harvard University found that among evacuees in Houston shelters, 55 percent of evacuees under age 65 and without children were uninsured. Many reported having serious health problems as a result of hurricane flooding, going without necessary health care, and suffering from chronic conditions such as heart disease, diabetes, and high blood pressure.

Why are these uninsured hurricane survivors are being turned away from state Medicaid programs? Under Medicaid eligibility categories, even if they are in serious financial need, evacuees are categorically ineligible for Medicaid unless they are: 1) under age 20, 2) pregnant women 3) parents with dependent children, 4) disabled, or 5) over age 65. In particular, low-income adults without children are categorically ineligble.

The "Emergency Health Care Relief Act of 2005", S. 1716 would provide at least five months of temporary Medicaid benefits for all survivors of Hurricane Katrina who have relocated to other states and eliminate categorical ineligibility for these evacuees. It would seem like a no-brainer. But this legislation is stalling and may be scaled back due to long-standing ideological differences that consistently stall health care reform.

A vote on the bill, which was introduced by Senators Chuck Grassley and Max Baucus on September 15th, has already been blocked in the Senate three times. Now, under pressure from the White House, Senator Grassley is considering scaling back the legislation. How can this be? Here's how a few persistent ideological debates that make all health care reform so contentious are turning even a bill for emergency coverage of hurricane victims into a battleground:

1) Public vs. Private Coverage

Public: Providing Medicaid coverage to hurricane victims is arguably the most efficient way to provide temporary coverage rapidly. Federal programs such as Medicaid provide reliable benefits, especially when access to private coverage is scarce for workers without jobs, and hurricane victims are in an unlikely position to exercise real choice among private health insurance options.

Private: Those who believe that health care should be provided through the private market are concerned that Medicaid is an inefficient government program that will be difficult to scale back. Moreover, expanding Medicaid will displace private health insurance coverage, sacrificing its benefits of personal responsibility and choice.

2) Federal vs. State Programs

Federal: Those who prefer federal legislation wish to ensure a standard level of benefits for Medicaid enrollees in different states. They fear that state budget problems and divergent preferences will prevent states from providing adequate health insurance coverage. They are concerned that a race to the bottom will occur if states are left to choose their levels of benefits.

State: The Bush administration opposes the bill because it argues that state Medicaid waivers make federal legislation unnecessary. HHS recently approved a waiver for Arkansas to provide Medicaid coverage to evacuees, and the administration favors the flexibility of these state level approaches.

3) Expanded Benefits vs. Cost Control

Expanded Benefits: S. 1716 would not only provide Medicaid coverage to those evacuees who would have otherwise been covered by Medicaid, but it would also eliminate categorical eligibility restrictions - most notably, those facing on low-income adults without children. Supporters of expanded Medicaid benefits believe they are necessary in a time of emergency.

Cost Control: The proposed legislation carries a price tag of $8.7 billion. Expanding health care coverage is expensive, as the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) promises to demonstrate. With the administration facing substantial hurricane recovery costs, critics believe this nearly $9 billion bill is too expensive and threatens Medicaid's long-term viability.

Arguably, emergency health care legislation should be immune from these broader ideological battles. A September 30, 2005 editorial in the Baltimore Sun argues, "Disaster spending should be smart, but its primary goal is to relieve human suffering." We certainly need a smarter health care system - with broader access, higher quality, lower administrative costs, and improved health outcomes. Yet, when "smart" is simply a euphemism for ideology, health care coverage should be sure to come first.