San Francisco's Latest Innovation: Universal Health Care

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San Francisco Mayor Gavin Newsom has a habit of treading where other elected officials are loath to go. First, he took on same-sex marriage. Now Newsom is angling again to bestow city residents with rights that Americans living elsewhere don't have. San Franciscans, he announced this week, are poised to become the first recipients of universal health care. This means uninsured city dwellers will gain access to basic medical services they otherwise couldn't afford. While not free, the care will come at sharply reduced costs. Enrollment fees will range from $3 to $201, depending on participants' incomes. Most, however, will pay $35 a month—far less than what HMOs typically charge.

It's part of an unprecedented program called "San Francisco Health Access Plan," which Newsom hammered out with labor, business, and city leaders. More than 82,000 San Franciscans who lack health insurance and do not qualify for Medicare or Medicaid stand to benefit. The majority are employed adults (children already have access to subsidized care); others are unemployed, self-employed, homeless, or have pre-existing conditions like diabetes, AIDS or cancer; some are even undocumented (yes: illegal) workers. Starting in early 2007, every uninsured San Franciscan can seek comprehensive primary care at the city's public and private clinics and hospitals, including top research facilities like the University of California at San Francisco. Coverage includes lab work, prescriptions, X rays, hospitalization and surgery. Annual funding for the $203 million program will come from re-routed city funds (including $104 million that now goes toward uninsured care via emergency rooms and clinics), business contributions and individual enrollment fees, which will be income-adjusted.

Newsom considers San Francisco's historic undertaking a "moral obligation," one that other city, state and federal officials have shirked. "We are implementing this. We're not waiting around," he told TIME. "It's no longer good enough to explain away our problem and to point fingers." Around 41 million Americans are uninsured. They inevitably wind up seeking medical attention from overburdened emergency rooms. The political dialogue must change, Newsom insists. "If it's not going to happen through national leadership or statewide leadership," he says, "then it has to happen on a local level."

Newsom and his supporters are convinced their ambitious plan will fly despite failed health reforms previously floated by Hillary Clinton and others. The key difference is that San Francisco's plan focuses on health access, not insurance. "This is really a plan that's focused on providing ėmedical homes' for people, preventive care. We can't solve all of the problems," says Dr. Mitch Katz, the city's public health director. "If our goal was to provide health insurance, at this point in time, we would fail, too."

Unlike medical insurance, San Francisco's health access program doesn't travel. It applies only to local residents who go for care within city and county limits. Emergency room visits outside San Francisco, for example, aren't covered. There's no dental or optometry coverage, and participants must be willing to apply for any state and federal benefits they are entitled to.

Still, universal health care in San Francisco isn't a slam-dunk. The city's board of supervisors must vote on the proposal, and details over financing must be sorted out. "It's wrought with potential pratfalls," Newsom acknowledges. The biggest snag is likely to come from the 15% of local businesses that don't provide their workers with health insurance and oppose a mandate that requires them to. Such a mandate is on the table now, but the public still needs to weigh in. On Monday the board of supervisors will take public comments. Lobbying will continue. "There's going to be a lot of rancorous debate," says Steve Falk, president of San Francisco's Chamber of Commerce. Should the mandate prevail, however, a legal challenge will surely follow, he warns, since hundreds of small and medium-sized businesses would be unfairly put at risk. "This mandate will fall on the companies that have the least ability to pay," he says.

Nevertheless, the thinking goes, if San Francisco's local plan for the uninsured takes off, it could be a model for other metropolitan regions nationwide. "This is a city that wants to right the proverbial wrongs," Newsom says. "We tend to march to the beat of our own drum and that, hopefully, is something that can awaken people's imaginations elsewhere."