Monday, July 17, 2006


Residents... are driving San Francisco officials to enact a unique but controversial program to offer inexpensive health care to residents who have none. Though the proposal resulted from months of negotiations among a myriad of interests, many in the city's business community oppose the legislation. They cite its requirement that employers set aside a minimum amount per worker to finance either private health insurance or access to the city's new program.

Nonetheless, the proposal is likely to win overwhelming board approval on Tuesday. Even Mayor Gavin Newsom, who describes himself as an ally of business, enthusiastically endorses the proposal and its financing component. "There is a fundamental here," he said during a press conference last week. "That is, an obligation to provide a strategy to create health care for 82,000 people where everybody participates (in its financing) -- employee, employer and government."

Advocates are near giddy about the program, calling it bold, innovative and a model for other local governments and the state. The San Francisco program "does create this sense of, if you can do something like this here, all but for leadership, good process, good deliberations, there is no reason we can't do this in California," said Dr. Sandra Hernandez, who co-chaired a mayoral panel that devised portions of the program. Those are "big ifs," she added.

For one, California voters in 2004 narrowly repealed a law requiring many businesses to pay for most of their workers' health coverage -- a concept that the San Francisco proposal borrows. And other local jurisdictions with a less robust medical infrastructure than San Francisco's may find such a program more difficult to implement. Under the Health Access Program, all San Francisco residents who are not already covered by insurance could enroll and select a primary care doctor. Participants would go to public and private clinics and hospitals for care, and be charged a co-payment based on their income. However, that care will not be "portable"; it could not be obtained outside San Francisco and would not be available to people living outside the city. Hence, the program cannot be called insurance.

Proponents who have long fought for large-scale government-mandated health insurance programs are untroubled by the distinction, given the financial and legal barriers the city faced in crafting the program. They note that people with health insurance frequently get care within their immediate community. The program, to be phased in starting next July, will cost an estimated $200 million annually. Half of that would by financed from funds the city already spends on indigent care. Co-payments would bring in about $56 million. State and federal funds would contribute as much as $20 million. The remainder will come from businesses, with 20 or more workers, which will contribute up to $1.60 per hour for each employee.

Companies can continue to offer coverage as long as it meets the minimum cost requirement set by the legislation. That would discourage employers from "dumping" their workers into the city program, supporters explain. Firms with fewer than 20 workers are exempt, as are nonprofits with fewer than 50 employees. Over time the program should reduce expenditures at costly emergency rooms, where many of the uninsured now go for care, supporters contend. It also should make for better workers who feel more secure about medical care, they add.

Supporters know they face hurdles drafting and implementing the details, and informing potential participants of the program. "The real challenge is going to be . getting the thing up and running," said Supervisor Tom Ammiano, the legislation's chief sponsor.

Business owners applaud the program's intent but blanch at the extra costs. "We want legislation that will work as opposed to legislation that will cripple small and medium businesses," Lara Truppelli, owner of two eateries, told supervisors at a meeting last week. "Your hands are in my checking account," said Susan Lieber, owner of a firm that provides workers for food events. "Don't make this a city of nothing more than chains because nobody (else) can afford to do business here."

Labor unions pushed for the proposal partly because employers are increasingly reducing medical coverage, said Paul Kumar of the Service Employees International Union's San Francisco local. By setting a minimum amount of coverage that companies must meet, the program would stop that erosion, he said.

Jim Lazarus of the San Francisco Chamber of Commerce said unions want to extend the concept of forcing employers to pay for health care into other counties and states. He said he expects someone to file a lawsuit to halt the city's new coverage, though the chamber has made no decision about that step. But political leaders are pushing forward nonetheless. Supervisor Bevan Dufty recounted how a waitress at a favorite restaurant who had no health insurance had to spend $10,000 to diagnose what turned out to be a benign lump in one breast. "There are going to be changes . in the economy of San Francisco" because of the program, Dufty said. "Maybe meals will become more expensive. . But (the city) is going to move forward just a little bit. And we're going to say that we care about people." [With other people's money!]


U.K.: Row over private healthcare role

Public sector union Unison claims the government intends to go ahead with the privatisation of primary care services. In June the Department of Health pulled an advertisement asking private firms to tender for key roles in health care management across Primary Care Trusts. A new ad has now been published in the Official Journal of the European Union, and Unison says it could lead to firms taking over "a huge range of services".

Health Minister Andy Burnham said it was about securing "quality support". Local health managers at primary care trusts (PCTs) currently buy in services, although in some areas it has been devolved to GPs. The government says it is only looking for firms to provide expert advice to PCTs and it would be up to local officials to decide if they wanted to use that private expertise. "If they're able to use the best possible advice and support available from around the world to do that job, then certainly as a health minister, I want them to have access to that high quality support," Mr Burnham told the BBC Radio 4 Today programme.

Last month, Health Minister Lord Warner withdrew an earlier form of the notice from an EU journal when it provoked uproar from unions. He said that a drafting error had been responsible for the mistaken impression that clinical services were up for tender. But according to Unison the new advertisement shows "very, very little difference" with the last one. "It's very clear that this new advert is inviting organisations to provide a huge range of management, health and support services across PCTs," Unison's head of health, Karen Jennings, told the Today programme.

She said other unions and professional organisations shared Unison's concern. "This advert not only enables PCTs to continue to outsource commissioning responsibility, but it's also so unspecified and open-ended in its nature, it is effectively allowing outsourcing to take place on the widest possible scale," she said. "So, for example, a private firm could come in and start to commission for other services for the NHS."

But Mr Burnham denied that the private firms were being brought in to decide what services were offered on the NHS. "They (PCTs) are publicly accountable for the services they commission on behalf of their local population - and that will not change."



For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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