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Some of the health care discussion focuses on health care for the most vulnerable, or some of the most vulnerable among us. Advocates for the homeless say that most people who lack shelter also lack medical insurance, and that puts a huge burden on the system. NPR's Pam Fessler reports.

PAM FESSLER: Most homeless people are too poor to buy their own health coverage, but many also don't qualify for Medicaid, the government-run health program for the poor. Medicaid is mainly for people who have children or a disability, and most homeless people are childless adults. So, like 63-year-old Walter Brooks of Baltimore, they make do.

Unidentified Woman: How much do you weigh, please?

Mr. WALTER BROOKS: Two-hundred, four pounds.

Unidentified Woman: Thank you. Please have a seat right here.

FESSLER: Brooks, a big, soft-spoken man, has been homeless on and off for the last seven years. What health care he does receive, he gets at a clinic run by a nonprofit group Health Care for the Homeless.

Brooks has high blood pressure, manic depression and a history of strokes, so he's a little embarrassed when physician assistant Jean Prevas notes that he hasn't been in for while.

Ms. JEAN PREVAS (Physician Assistant): Is anything bothering you that make you say today's the day I need to go to the doctor?

Mr. BROOKS: No. I've been procrastinating about coming, because I didn't want to get yelled at.

Ms. PREVAS: Now, you know I don't yell at you.

(Soundbite of laughter)

Ms. PREVAS: I just give you looks.

Mr. BROOKS: Yeah.

FESSLER: Prevas is concerned because Brooks' blood pressure is exceptionally high, and his lungs don't sound very good, either.

Ms. PREVAS: Big breath. Out. Big breath. Out.

FESSLER: This clinic sees about 200 homeless people each day, at no cost to the clients. Many, like Brooks, have serious health problems and nowhere else to go, except maybe to an emergency room.

Jeff Singer is president and CEO of Health Care for the Homeless at Maryland.

Mr. JEFF SINGER (President and CEO, Health Care for the Homeless): In 41 states, single adults are not eligible for Medicaid, and Maryland is one of those states. So you can have zero income and still not be eligible for any sort of health insurance.

FESSLER: He says that's true for about 70 percent of the patients Health Care for the Homeless sees nationwide. The group uses donations and government grants to provide care, but Singer says that's not very efficient.

He says a lot of people are homeless because they have health problems that cost them their jobs and eventually their housing, and that sets off a downward health spiral that's expensive and difficult to stop.

Mr. SINGER: Because it's very, very harmful to your health to live outside, or even to stay in a shelter. Homelessness causes health problems, it exacerbates health problems, and it makes it very complicated to treat health problems.

FESSLER: So he and other advocates have been encouraged by the health care legislation now moving through Congress. The House-passed bill would expand Medicaid coverage for the first time to millions of low-income adults, and the Senate Finance Committee is considering a similar move.

But there's a big catch. Concerns about how to pay for the health care bill are growing, and the Medicaid expansion alone is expected to cost more than $430 billion over the next 10 years. That has the nation's governors, who usually bear a share of Medicaid costs, very worried.

Governor JIM DOUGLAS (Republican, Vermont; Chairman, National Governors Association): Governors agree that there cannot be an unfunded mandate. It cannot be passed onto the states to pick up the tab.

FESSLER: Jim Douglas is Vermont's Republican governor and chairman of the National Governors Association. He notes that most states are already having trouble meeting basic needs because of huge budget deficits.

Gov. DOUGLAS: We have to make sure that we don't expand a program that we can't afford to pay for over the long term.

FESSLER: And he says he's not reassured by proposals in Congress to have the federal government foot the entire bill to expand Medicaid, but only for the first two years.

The governors' opposition comes on top of broader discontent over the cost of the health care bill. Lawmakers such as Maryland's Democratic Senator Ben Cardin had been shouted down by angry crowds this summer, when they tried to defend proposals to extend coverage to the poor.

Senator BEN CARDIN (Democrat, Maryland): A lot of people who use the emergency rooms are using the emergency rooms because they have no other place to go. They then become part of the uncompensated care. They enter the hospital. They don't pay their bills, and then the hospital has to raise the rates on all of us.

Unidentified Woman: But this bill…

Sen. CARDIN: So what we're trying to do…

Unidentified Woman: No, senator, I'm sorry…

FESSLER: Opponents of the legislation say they don't trust the federal government to run the program efficiently and have vowed to defeat the bill.

Homeless advocates say they hope the needs of their clients don't get lost in this larger debate. They say people will end up footing the bill for the homeless one way or the other.

Pam Fessler, NPR News.

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