Doris Brisson lives on the outskirts of poverty in Mesquite, Texas. The 66-year-old gets Social Security payments of $512 a month and food stamps worth $20 a month, and she barely makes the rent on a one-room apartment that she says gives cozy a bad name.
While Congress has grappled with vast overhauls of the two giant health care programs independently, for Mrs. Brisson, and for as many as 5 million other elderly poor people, the programs are nearly indivisible. To maintain their precarious existences, they depend on both.
The anticipated growth of the two programs would be sliced by more than $440 billion in seven years under Republican legislation that passed Congress last month and that President Clinton has threatened to veto.
Republicans maintain that by giving states more flexibility on spending their Medicaid dollars and by directing older people into cost-conscious managed care plans, the government will save money while improving health care and reducing costs for people like Mrs. Brisson.
But numerous health care experts and advocates for the poor say that the financially pressed and often frail elderly, vulnerable to cuts in both programs, will become the legislation's most pathetic victims.
Studies have shown that nearly 1 million older Americans living in poverty stand to lose some of their health coverage if these changes become law.
"For them it's a double whammy," said Ron Pollack, executive director of Families U.S.A., an advocacy group. "They could lose Medicaid eligibility at a time when the Medicare expenses that Medicaid used to cover for them are going up. If they couldn't afford them before, how will they afford them now?"
In Mrs. Brisson's case, Medicare pays for her doctor visits, but her premium, copayments to her doctor and her annual deductible are covered under Medicaid.
The Medicaid program, the Qualified Medicare Beneficiary program (QMB), has required since 1990 that states pay those Medicare costs for beneficiaries who are barely above the poverty line, about $7,400 for a single person and about $10,000 for a couple.
But neither program covers medicine.
Mrs. Brisson is supposed to be taking medication for high blood pressure, arthritis and depression. She has the prescriptions in her purse, next to the wallet that holds too little money to get them filled.
"Right now, what I can't get free from the doctor, I do without," said Mrs. Brisson, who has had trouble getting full Medicaid benefits after a recent move from Colorado to Texas.
"By the end of the month I'm begging dinner invitations from friends. If anybody asks me to spend one more dollar for my health care, well, I guess I'd just have to quit going to the doctor altogether."
The Republican Medicare plan raises beneficiaries' copayments, deductibles and premiums and encourages them to join cost-saving managed care plans.
By signing on for such a plan, the Republicans argue, older people with limited resources would no longer have to pay a portion of each doctor visit or a minimum amount before their benefits kick in.
The Medicaid plan, meanwhile, ends mandatory benefits for the very poor and gives states fixed grants that they would decide how to divide among their neediest residents.
Whether states would put as much money as the federal government now requires into covering gaps in the Medicare coverage for the elderly poor is very much an open question.
"Even if you had a combination of Mother Theresa and Albert Einstein administering these programs, the proposed cuts are so deep that needy people will lose eligibility," said Stan Dorn, managing attorney for the National Health Law Program, a public-interest law center in Washington and Los Angeles that focuses on low-income health issues.
Being forced to cut back on the medical attention they get, Mr. Dorn said, will have deadly consequences for the elderly poor. "The death certificate may say 'Cause of Death: Heart attack,' " he said. "But the real cause will be Medicaid and Medicare cuts."
Republicans said that given the spiraling costs of Medicaid and Medicare, they had no choice but to find a way to rein in expenses.
"We are opening up Medicare to the new medicine of the '90s," said Mike Collins, a spokesman for the House Commerce Committee. "States and managed care providers are going to give better care at lower costs to our needy seniors."
But a study by the Urban Institute, a Washington-based research group, found that even as suming that state governments achieve a higher level of cost efficiency in their managed care programs, nearly 1 million poor older Americans could lose their Medicaid eligibility in the next seven years.
Another report by Project HOPE, a Washington think tank that studies health issues, found that nearly 60 percent of people eligible for Medicaid's QMB program did not receive benefits because they did not know about the program or did not realize they qualified.
But as the economic situation for poorer older Americans declines, experts warn that more of them will be forced to seek protections, like those now offered under the QMB program.