“We want to put health care on the front burner,” says San Francisco Supervisor Tom Ammiano. The Board of Supervisors is poised to approve, for the second and final time, legislation that would extend health coverage to 82,000 uninsured San Franciscans. Last week, the Board voted 11-0 in favor of the plan on its first reading. Ammiano and his fellow Supervisors, Mayor Gavin Newsom and policymakers in Massachusetts and Vermont, understand that the American health care system is broken – it costs too much and leaves too many without coverage – and they are taking action.
The San Francisco universal healthcare plan emerged from a fast-moving, complex political process characterized by productive compromise. Newsom created the Universal Healthcare Council in early 2006 to develop the parameters of a program to provide healthcare services to uninsured San Franciscans. The council recommended the San Francisco Health Plan, a locally developed, State-licensed plan that already provides care to Medi-Cal clients, and expanding the role of the existing public provider network. Newsom and Ammiano forged a compromise between this plan and alternative visions that emphasized employers’ responsibility for health coverage. The final legislation establishes health coverage for the uninsured and requires employers to help finance the program through a per-worker, per-hour assessment. Consumer contributions, through premiums and copayments, and city funds will also contribute to program costs.
San Francisco’s effort is laudable, but it also points to the limitations of state and local initiatives. Since San Francisco is building this program on the foundation of the city’s existing system of physicians and clinics serving Medi-Cal patients and other poor residents, the plan will not be able to provide medical treatment outside of city limits. Replication may be difficult as well—many other cities do not have an existing county-operated health plan or similar administrative infrastructure for launching this kind of program, and the unique combined city and county structure of San Francisco means that the city, unlike many other municipalities, already has a large financial stake in caring for people without health insurance.
Other state efforts have met with frustration or failure. Last week, a federal court decision struck down Maryland’s “Fair Share” law, which requires employers with more than 10,000 workers to spend at least 8 percent of their payroll on health insurance, or pay the difference to the state to offset public health insurance costs related to their employees. In this ruling–which could have implications for future state and local efforts–the court found that the Employer Retirement Income Security Act (ERISA), which enables multi-state employers to establish national benefit programs that are exempt from state regulation, pre-empts the state’s effort to require very large employers to pay their “fair share” of health care costs. And in 2004, California voters narrowly rejected Proposition 72, which would have required employers with 50 or more employees to “pay or play” by either providing coverage for their employees or paying a fee to the state, which would purchase coverage on the employees’ behalf instead.
These limitations and frustrations of local and state efforts – and the occasional outright failure – point to the need for a national solution to our health care crisis. Yet our national political leaders have failed to acknowledge or address the problem. The White House and Congress created a Medicare prescription drug program that enriches prescription drug manufacturers and the health insurance industry, as well as promoting health coverage policies, such as broader tax breaks for Health Savings Accounts, which some analysts predict will lead to even more Americans losing health coverage. Even the Democratic Congressional leadership has focused on fixing the Medicare prescription drug program rather than addressing the larger challenge of ensuring affordable coverage for all Americans. These leaders have ignored the public’s deep and broad interest in reforming our broken health care system, as indicated in a recent poll, instead offering incomplete and inadequate responses. As Andy Stern, President of the Service Employees International Union noted recently in The Wall Street Journal, “the problem isn’t policy, it’s leadership … the political class in both parties is full of words and bereft of action.”
In the absence of national leadership, San Francisco will forge ahead. Tomorrow’s vote in San Francisco will add more mass to the movement to provide affordable health care for all Americans, thus building momentum for national change. Other leaders – our national political leaders, business executives, physicians and other stakeholders – should derive inspiration and motivation from the City by the Bay and make reforming our health care system a national priority.
Karen Davenport is the Director of Health Policy at the Center for American Progress