Federal judge rules against S.F. on health care plan

A federal judge scaled back San Francisco's groundbreaking health insurance law Wednesday, overturning a requirement that employers cover their workers or pay a fee - the key to the city's plans to provide coverage to all 82,000 uninsured adult residents next week. U.S. District Judge Jeffrey White described San Francisco's goal as "laudable" but said its ordinance - the first of its kind in the nation, and a potential model for other California cities and the state - conflicted with a 1974 federal law that prohibits state and local governments from regulating employees' benefits.

The ruling, if it stands, will require the city to reduce plans to extend health coverage Jan. 2 to all uninsured residents who aren't already covered by the Medi-Cal program for the poor or by Medicare for the elderly.

Tangerine Brigham, director of the city's health benefits program, said Wednesday that if the employer fee was struck down, city officials would limit the expanded enrollment to residents who make no more than three times the federal poverty level, or about $32,000 a year for an individual. The employer fee would let the city extend coverage to all uninsured residents.

White's ruling could also impede other state and local efforts to cover the uninsured in the absence of a national law. A state health care bill endorsed by Gov. Arnold Schwarzenegger and approved by the Assembly would be partly funded by employer fees, subject to state voters' approval.

City Attorney Dennis Herrera said he would ask the Ninth U.S. Circuit Court of Appeals Thursday for an emergency stay that would allow the employer fee to take effect as scheduled Jan. 2 while the city appealed White's ruling. Without a stay, Herrera said, "tens of thousands of San Francisco residents and workers will be deprived of critically necessary health care services." Mayor Gavin Newsom said the program has enrolled more than 6,500 people and will be enlarged next week, even without the employer fee. "We will move forward with this innovative program," he said.

An official of a restaurant association that challenged the fee said the city should reconsider other ways to fund the program, such as a quarter-cent local sales tax, which would require voter approval. A general tax increase would spread the costs among businesses, residents and tourists and "would help fund the program in a legal and sustainable fashion without crushing small businesses," said Kevin Westlye, executive director of the Golden Gate Restaurant Association, which has more than 900 members.

The ordinance, enacted last year, established a $200 million-a-year program to care for the uninsured. More than three-quarters of the money was to come from city tax dollars and patient premiums, and the rest from the employer fee that was the subject of White's ruling. Private employers with at least 20 employees and nonprofits with at least 50 employees were to be given two choices: provide health coverage, at spending levels set by the ordinance, or pay a fee to support the city health program, which was budgeted at $200 million a year.

City lawyers, joined by a group of labor unions, argued that the city was not regulating employee benefits - which federal law forbids - but was simply making health care available to workers whose employers chose not to provide it. They said federal law allows a local government to require employers to share in health care costs as long as companies can comply without setting up new health plans.

But White said the ordinance would regulate employer health plans by requiring businesses to spend certain amounts on each employee - changing their existing, federally governed plans - or pay a fee. "By mandating employee health benefit structures and administration, those (spending) requirements interfere with preserving employer autonomy over whether and how to provide employee health coverage, and (with) ensuring uniform national regulation of such coverage," the judge said.

Deputy City Attorney Vincent Chhabria, who argued the case for the city, said White's ruling was extremely broad and would prohibit any state or local government from requiring employers to spend money for health care. The program, titled Healthy San Francisco, was the result of a collaboration between Newsom and Supervisor Tom Ammiano. It began in July at two clinics in Chinatown.

The program is currently available to people earning less than the federal poverty level, which is $10,210 a year for one person or about $20,650 for a family of four. On Jan. 2, it is due to expand to those making up to three times those amounts, a limit the city was forced to impose because of Wednesday's ruling. "What the ruling does is limit overall participation," said Brigham, the program director. "There are a lot of people who earn above 300 percent of the federal poverty level who are uninsured. ... Certainly we are disappointed."

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Australia: Why private health insurance is a good idea

We see below part of the reason why nearly half of Australians have private health insurance despite the fact that they can allegedly get their healthcare "free" from government hospitals. The government health system could simply not have afforded many of these procedures and would have covered it up by putting you on an interminable waiting list. The high cost of cardiac procedures is probably the real reason why the Queensland government has recently closed down or curtailed cardiac units

A claim of more than $300,000 for neurosurgery to repair a complex aneurysm has topped the 10 most expensive benefits paid by Medibank Private in the past financial year, setting a record. The fund will release its "chart toppers" today, which climbed to $2.3 million for the top 10 across Australia, representing an annual increase of 8.3 per cent. The highest benefit paid, of $304,119, was on behalf of a 59-year-old person from NSW, up from the previous financial year's top benefit of $276,247 for a coronary artery bypass on a 59-year-old person.

It was followed by a 46-year-old Victorian - the youngest person on the list - who required removal of a tumour from their adrenal gland at a cost to the fund of $283,211. The oldest patient was 83 and needed cardiac surgery, costing the fund $230,876. Last year, the largest benefit paid was $276,247 for a coronary artery bypass. Five of the 10 claims were for heart-related procedures.

The fund paid $1.95 billion for hospital, medical and prosthesis benefits in 2006-07, representing 750,000 hospital admissions. The five most common overnight procedures claimed for were natural birth, at an average cost of $5234, followed by caesarean ($7601), rehabilitation ($8546), knee replacement ($19,065) and keyhole surgery for gall bladder removal ($5120). The five most common same-day procedures were colonoscopy, at an average cost of $1321, chemotherapy ($547), renal dialysis ($351), gastroscopy ($924) and cataracts ($3096).

Medibank's industry affairs manager, Craig Bosworth, said the "chart toppers" showed that medical care was increasingly expensive. "The odds are at some point in our lives we will need to go to hospital. The other certainty is that health care costs will continue to rise and, as the chart toppers list shows, can hit incredibly high levels," he said.

NSW patients were paid a total of $485 million for hospital, medical and prosthesis benefits. The top 10 claims in NSW totalled $1.73 million, the same as Victoria, compared with $1.25 million for Western Australia, $1.69 million for Queensland, $1.14 million for South Australia, $787,000 for Tasmania and $529,000 in the ACT. In the NSW top 10, four claims were for cardiac surgery, two were for aneurysm repair, two for stomach surgery, one for vascular surgery and another for a complex fractured thigh which ranked seventh with a benefit paid of $134,435.

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