WASHINGTON — 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.