Shana Larsen is in front of her laptop in the dining room of her Beaverton townhouse. She’s been shopping for her own health insurance, armed with hard-won knowledge. Her husband, Greg fought a four-year battle with cancer.

Larsen says, “He was diagnosed in 2006, when he was 29. The big thing that tipped me off is we were training for Hood to Coast, and he was very athletic, and he couldn’t run a mile without running out of breath.”

As the illness took its course, Shana became more deeply immersed in dealing with the bills for Greg’s treatments, which she estimates at well over a $1 million.

“It was more confusing than anything, because you don’t think about where all the money’s going to come from at first. We ended up keeping an Excel spreadsheet of all of the bills, trying to keep track of them that way,” Larsen said.

Greg died in April. Now, Shana Larsen is re-entering the health care universe as a consumer and a voter. She says she takes a very different view of health care policy, because of her experience.

CD-1 (2010)

How CD-1 Residents Pay For Hospital Visits (by percentage):

Commercial Insurance: 44.05
Medicare: 37.31
Medicaid: 12.99
Self-Pay: 5.64

STATEWIDE (2010)

How Oregon Residents Pay For Hospital Visits (by percentage):

Commercial Insurance: 37.94 (down 1.29% from 2009)
Medicare: 41.35 (up 0.24% from 2009)
Medicaid: 13.82 (up 0.72% from 2009)
Self Pay: 6.88 (up 0.32% from 2009)

“Things you don’t think about when they’re choosing health care, is limits. Yearly coverage limits, life-time coverage limits. As I’m shopping now,. I’m noticing that a lot more, that a lot of plans have these limits to them,” Larsen said.

From coverage limits to drug coverage, Larsen’s much more aware of how different insurance plans can mean the difference between getting a key treatment or going without. As she looks over premium options, she’s thinking about access to health care in an entirely new way.

Access has been a focal point in the First District candidates’ discussions of health care policy. Democrat Suzanne Bonamici has addressed it in terms of her experience in the state legislature. She’s voted on bills that will re-tool Oregon’s insurance markets to meet federal mandates over the next three years.

“I know that health care needs are significant, and I know the most important thing is to make sure people are covered. Until we have universal access, we won’t be able to drive down costs. What happens now is that people who don’t have coverage get their health care needs met in the most expensive place. That’s the emergency room,” said Bonamici.

Bonamici also says she says she’ll focus on mental health care needs and support providers as they modernize their work with electronic records and telemedicine.

As a voter, Shana Larsen is certainly concerned with access. But as a self-employed personal chef, she also keeps an eye on costs. That’s the sensibility Republican Rob Cornilles tries to address.

“On the federal level, I believe it’s the responsibility Congress to pass legislation that will allow costs to go down,” said Cornilles.

Cornilles is a Tualitin businessman who has said he would not have voted for the Obama Administration’s Affordable Care Act, as it was presented. But he also does not favor the repeal some other Republicans tried to pass last year. He describes his approach to health care policy as cost conscious.

Cornilles said, “Every year I’ve been in business, my health premiums have gone up, for me and my employees. And we’re a pretty healthy group. There are a lot of ideas that have been out there for years that they don’t have enough political courage on either side of the aisle to enact.”

Cornilles says he thinks building greater portability into health care markets is a first step.

While the national health care debate has fallen out of the headlines, it’s apparent Congress’ work on the issue is far from done. When Gov. John Kitzhaber delivered his State of the State address last Friday at the City Club of Portland, he talked about Oregon’s efforts to overhaul Medicaid and other state-sponsored programs. The goal, he says, is to get ready for a big coverage expansion mandated by the Affordable Care Act – and, at the same, time, improve the quality of care.

Kitzhaber explained, “The business plan for our new coordinated care organizations shifts the focus and the financial incentives from the emergency room to wellness, prevention, and early intervention, and the community-based management of chronic conditions like diabetes and congestive heart failure.”

To do this, Kitzhaber and other state officials will need a series of waivers from the federal government, allowing Oregon to spend Medicaid money in different ways. Last week, he spent a few days in Washington DC, talking to officials about waivers. Assuming the Legislature acts next month to set the changes into motion, the Governor will seek help from the Congressional delegation to secure the waivers he says are critical to make Oregon’s health care system work.

Democrat Bonamici says she believes in what’s happening at the federal and state levels.

“If there’s anything I can do to be helpful with the implementation of the insurance exchange, I’ll be right there to do that. When you look at what’s happening in Oregon, our insurance exchange, our transformation, increasing access through community care, more primary care,” she said.

Those, Bonamici says, are the changes that will bring costs down across the system.

Republican Cornilles takes a sharply different view of the federal mandates.

“As I understand it, as a small business owner, I’ll be forced to pay for a more expensive program, or I’m going to have to turn my employees over to a public plan,” he said.

While Cornilles’ concerns about cost have been often repeated, federal and state officials say they believe the federally-mandated changes will keep costs under control in the long run.

But Cornilles says he supports Gov. Kitzhaber quest for waivers for Oregon. He says he hopes that, in doing so, the state can reduce the burgeoning cost of health care while improving access. He also says he can think of a better model than Medicaid for covering those with low incomes who are uninsured.

“What we do have in Oregon that’s a really good model is federally-qualified community health centers. There are six clinics in Washington County and Yamhill County combined. These are six clinics in Washington County and Yamhill County, combined. These are community-based entities that provide health care for people who are uninsured,” he said.

Cornilles says he believes this model would be less expensive than trying to buy monthly insurance for people who are not currently covered.

Both candidates rate access to care as one of the fundamental problems facing the health care system. They also say they’d be interested in attacking other problems specific to the First District – like a lack of access to primary and acute care. The federal government labels Columbia County, for example, as an area that has a shortage of health professionals.

Cornilles says he’s interested in increasing the number of doctors across the region.

Bonamici says she’d support boosting the number of professionals who can do primary care at a lower cost than doctors — like nurse practitioners.

Beaverton resident Shana Larsen knows she experienced the health care system at its most extreme. But Larsen points out that many people have anxieties around health care today.

“Most of my friends are having children and worrying about coverage on some of the normal stuff that happens – going to the pediatrician,” she says.

And, above all, she knows first hand how important it is to think about the tough issues that come up around health care policy.

Larsen says, “I’m glad people are talking about it. It’s incredibly important.”