The Golden Gateway to health reform...

Wednesday, September 03, 2008

Healthy San Francisco gets the full treatment in a paper by Community Catalyst. "Healthy San Francisco: A Case Study of City-Level Health Reform" is a description of the politics and policy of the groundbreaking effort, written for health advocates in other states and nationally to learn lessons and take inspiration for their efforts.

Even in tough week, we see that California can lead the way. It's up to us not to give up...

Labels: SanFrancisco, YearOfReform

posted by Anthony Wright | Permalink | 11:36 AM


 

Sunny San Francisco...

Tuesday, July 08, 2008

It's was a sunny, optimistic day in San Francisco, as Mayor Gavin Newsom addresses the crowd on the steps of his City Hall, at the one of the over 50 launch events for the Health Care for America Now! campaign for federal health reform. "We've been here on these steps many times before, saying many of the same things. But this time feels just a little bit different. This time it feels like we share a feeling of a little more optimism." said Newsom.

"This is not just an ethical issue, though it is. This is not just a moral issue, though it is. This is an economic issue," the Mayor said. On the stalled effort in Sacramento, he said "we were that close. We were right there on the cusp on fundamental change. We know what needs to be done. Its time for leadership to get the job done."

Giselle Quezada of ACORN and Anthony Wright of Health Access California moderated the event and are to the left of the Mayor in the picture. Also pictured are John Arensmeyer of Small Business Majority, Leah Donahey of CREDO Mobile, and Dr. Stuart Bussey of the Union of American Physicians and Dentists of AFSCME.

Other speakers included Art Pulaski of the AFL-CIO, Conny Ford of the San Francisco Labor Council, Dr. Rachel Krebs-Falk of the Committee of Interns and Residents, Paul Kumar of SEIU-United Healthcare Workers West, and Amy Moy of Planned Parenthood Golden Gate. We had 20 media outlets attend, including television, radio, newspapers, and magazines.

It was a successful start to an important campaign.

Labels: Federal, SanFrancisco, YearOfReform

posted by Anthony Wright | Permalink | 8:23 PM


 

California's unique voice...

With the announcement of the Health Care for America Now! campaign to push for national reform with a new President and a new Congress at the beginning of 2009, some may wonder about California's role in this national effort.

First things first: this is no way supplants or suggests a lack of commitment to the ongoing, multiple-year effort for state-based reform. That effort is ongoing, and will be highly coordinated with this new federal effort. We think there is an opportunities for health reform at both the state and federal levels in 2009. We simply think the federal government should be a partner and a leader for health reform, rather than an obstacle, which has been its position for several years.

More than that, California can and should be a leader in influencing the national debate. And it is well equipped to do so. The two locations for launch events tell the tale:

* No state feels more urgency for health reform than California. One of our events is in front of Los Angeles County Hospital spotlighted the city as “ground zero” for the health care crisis nationally, with closing emergency rooms and one of the highest rates of uninsured in the nation. Nobody needs health reform more than Californians facing a broken health system.

* No state will have a bigger voice in the debate, given our sizable and powerful Congressional delegation, led by the Speaker of the House, Nancy Pelosi, and key committee chairmen like Reps. George Miller, Pete Stark, Henry Waxman, and other leaders.

* No state has more experience considering and debating the various options for health reform over the last five years than California, at the state and even local level. Our event in front of City Hall in San Francisco spotlighted a city that not only hosts the leader of the U.S. House of Representatives, but that also shows health reform is possible—and meets many of the principles advanced by consumer advocates. The city last week just celebrated the one-year anniversary of the implementation of their universal healthcare program, Healthy San Francisco.

California has no choice but to be a leader in the national effort. And an important part of that is leading by example, by moving state-based reforms on a parallel track with the national conversation.

Labels: Federal, SanFrancisco, YearOfReform

posted by Anthony Wright | Permalink | 1:30 AM


 

An unprecedented national effort...

Monday, July 07, 2008

Later today, Health Access and many other key groups in California will help launch of a major campaign to win national health reform in 2009. The scale of the effort, called Health Care for America Now, is unprecedented ($40 mill, over 100 groups, over 100 organizers in 45 states) for comprehensive health care reform in 2009.

It is part of a national launch in over 50 cities--and 37 state capitols--across the nation, and in Washington, DC, featuring Elizabeth Edwards. The effort has already gotten important attention by Jonathan Cohn at The New Republic and Julie Bosman at The New York Times.

The California events in San Francisco and Los Angeles have their own star power, featuring SF Mayor Gavin Newsom and Lt. Gov. John Garamendi, both nationally-recognized leaders with significant health reform credentials, joining California Labor Federation leaders Art Pulaski and Connie Leyva and leaders of key community, consumer, business, and health care groups.

We'll have more coverage later today and the week, reporting about the activities of this broad ranging coalition. Leading the field effort in California is Health Access California, California ACORN, and the California Partnership, in active partnership with many of the California groups participating in the launch events, including: the California Labor Federation, AFSCME, CREDO Mobile, MoveOn, California Teachers Association, Committee of Interns and Residents, Planned Parenthood Affiliates of California, SEIU, Small Business Majority, Universal Health Care Action Network, United Nurses Association of California, United Food and Commercial Workers, and others. More later...

Labels: Federal, SanFrancisco, YearOfReform

posted by Anthony Wright | Permalink | 6:55 PM


 

The insurance companies come to town...

Wednesday, June 18, 2008

America's Health Insurance Plans (AHIP) is having its conference this weekend, starting tomorrow, Thursday, at the Moscone Center in San Francisco.

Healthcare activists both in-state and nationally are hosting a rally for a "Health Insurance DAY OF ACTION." It is:

Thursday, June 19
12pm – 1:30pm (Pacific Time)
4th and Howard Streets, San Francisco (map)

More information is available at:
http://singlepayernow.net/

My only question is: what were they thinking? To come to the state where their notoriety has only increased with the rescission issue, where a single-payer bill is moving in the Legislature, where policymakers of both parties want to place new rules over their behavior... it just seems masochistic.

It's a good opportunity to put the spotlight on the problems with insurance companies practices in general, and to voice support for single-payer health care (including SB840 and HR676) in specific. Especially if you are in the Bay Area, it's worth your lunch hour and afternoon.

Labels: Insurers, SanFrancisco, SB840

posted by Anthony Wright | Permalink | 3:55 PM


 

Bush vs. San Francisco...

Thursday, April 17, 2008

As if San Francisco didn't need more bad press this week, the Bush Administration is weighing in against Healthy San Francisco in court today, reports Bob Egelko of the San Francisco Chronicle.

Here's some previous posts on the background of the Healthy San Francisco effort, including the legal ERISA challenge to the San Francisco program, to strike down the policy of getting employers to contribute to the health care of their workers.

There's a hearing today at the Ninth Circuit Court of Appeals. Given that effort around Healthy San Francisco came about in part because of federal inaction on health reform, it's disappointing that the White House couldn't stay out of it, and allow state and local groups to proceed with their own reforms.

Labels: Bush, Employers, SanFrancisco

posted by Anthony Wright | Permalink | 8:03 AM


 

SF Suing Sacramento...

Tuesday, March 25, 2008

San Francisco Mayor Gavin Newsom visited with leaders of the state government in Sacramento today, and announced he was going to sue them. Their decisions are messing up his Healthy San Francisco program, which could provide access to health services to half the city's uninsured population by the end of the year -- granted it gets the money it needs.

Specifically, Newsom (or rather, his city) is seeking an injunction against the 10% reduction in reimbursement rates to providers who take care of Medi-Cal recipients. The yet-to-be-filed lawsuit is seeking a broad coalition of co-plaintiffs to stop the $544 million cut, which takes effect July 1, from going forward.

Newsom's legal action is a criticism of both Gov. Arnold Schwarzenegger and lawmakers -- both Democrat and Republican -- who are seeking to balance the state budget through a cuts-only strategy. The state is facing a $14.5 billion -- and growing state budget deficit. In February, the Legislature and Governor agreed to an approximately $1 billion package of midyear cuts, which included the Medi-Cal rate reduction.

The rate reduction is bad news for Medi-Cal recipients statewide, who already have a hard time finding doctors who'll take them. California ranks 42nd in the nation in provider reimbursement rates; primary care providers are paid between $18 to $24 for seeing patients.

In San Francisco, this rate cut translates to an $8.7 million loss to the city's public health department -- a figure that does not include the network of private practice physicians who also see -- or don't see -- Medi-Cal recipients.


"The impact is already being felt," and some physicians are refusing to take appointments from Medi-Cal patients, Newsom said. That means 123,000 Medi-Cal recipients in San Francisco are going to have a harder time getting health care, and they will suffer. Those who get really, really sick will end up in San Francisco General Hospital's emergency room, which will shift costs to other patients and in other ways to the local economy. It's a burden on everyone, it's unfair and that's what Newsom will argue in court.



I'm a little disappointed, though, that Newsom didn't come out more strongly in favor of a solution--one that includes revenues. He knows one of the problems is that we don't have enough money. The state has chosen to shuffle money hither and yon and enact budgets that slid out of balance the minute they were signed into law.

Given his experience in budgeting with massive deficits ($300 million in SF this year), he knows the need to increase revenues. He admitted that he has raised fees to the hilt and has run out of new fees to increase. Still, he stopped short of supporting higher taxes/fees/revenues, saying tepidly, "I don't believe in a tax-first strategy. But given the magnitude of the problem, it would be wrong not to have revenues on the table."

While taxes and revenues are the long-term solution, the Mayor's announcement is an important immediate tactic, to not take the cuts laying down. In San Francisco, Newsom is actively supporting his Healthy San Francisco program, which he says should be a model for the state. But, he said, "other health care programs will get cut. This money comes from somewhere. Finding a way to get it done will impact other programs in the city. there will be layoffs within the city as a consequence.'

It's nice that there is a high-profile ally who will shed light on budget cuts--he predicts that these cuts will have a big impact on San Francisco--a county that comparatively spends more on health care than others. If that's the impact in SF, how much worse will it be in the rest of the state?

Labels: Budget, SanFrancisco

posted by Hanh Kim Quach | Permalink | 8:36 PM


 

Looking back, looking forward...

Thursday, March 20, 2008

Steve Wiegand of the Sacramento Bee brings us a fascinating blast from the past, explaining some of the details with Gov. Earl Warren's attempt at health care reform many decades ago. The question is whether the current Republican Governor's second attempt at health reform (he says he's committed) will be more successful...

Lots of posts about state and national health reform in this week's Health Wonk Review, hosted by Joe Paduda at Managed Care Matters. It nicely spotlights our recent post asking what's wrong with the restaurants...

Ground zero in health care reform (at least one of the 'zeros') is San Francisco, perhaps the largest political entity in this country to legislate universal coverage. Anthony Wright finds the most vocal opposition to Healthy San Francisco came not from insurers, or pharma, or physicians or neocons, but restaurants. From his desk, it looks like the restaurant's opposition may be backfiring, as some patrons are happy to pay a surcharge to cover their server's health benefits.

I've always said that given the raw numbers, Los Angeles was the ground zero in the uninsured crisis in the nation--so maybe it's appropriate California offer a ground zero in the solution--hopefully Sacramento will re-establish it's claim to that mantle as well.

Other interesting posts noted include:
* a series on the state of America's health system by Tom Lynch (a four-part post: One, Two, Three and Four), trying to answer the question is our system is the best in the world...
* a Colorado look at a proposal to allow out-of-state plans to offer coverage by Louise Norris--she notes all the problems with such a proposal in terms of undermining state consumer protections and markets; and while these consumer protections are national, I think there's a role for the states in insurance regulation;
* and Jason Shifrin on a minimum benefits requirement for health insurance--an issue we are trying to tackle with SB1522 (Steinberg), which we believe strikes the right balance, allowing lots of choice and variation that is in the insurance market right now, but have some standardization to prevent the "junk" insurance plans that really don't provide even catatrophic coverage, and allow for apples-to-apples comparisons for consumers.

Labels: Insurers, OtherBlogs, SanFrancisco, YearOfReform

posted by Anthony Wright | Permalink | 3:11 PM


 

Eating out in San Francisco

Monday, March 17, 2008

Quick. What special interest is the most active opponent against comprehensive health reform?

While many compete for that distinction (insurers, doctors, drug companies, etc.), there's a strong argument that it is... the restaurants.

As the industry perhaps most likely not to provide health coverage to their workers, they have consistently opposed efforts that would require them to contribute a fair share to health care.

* Many have been actively opposed to single-payer at least since the 1994 ballot measure--with some even subjecting patrons to anti-Prop 186 table cards.

* Fast food and chain restaurants were the single largest opponents of SB2 and Prop 72, which would have required large employers to pay for their worker's health care. In fact, fast food and chain restaurants--from McDonald's and KFC to Applebee's and Cheescake Factory--made up over 70% of the opposition fundraising to Prop 72--most of the rest of the employer community stayed on the sidelines. Without the California Restaurant Association, Prop 72-which lost by less than a percetnage point--would have been enacted.

* Despite Governor Schwarzenegger's urging, they ultimately opposed AB x1 1. In opposing an minimum contribution for employers to health care, they graciously offered to support a sales tax--a tax they don't pay, but that their customers and other businesses do.

* In San Francisco, the Golden Gate Restaurant Association--rather than the Chamber of Commerce or broader business interests--has led a lawsuit to overturn Healthy San Francisco. The lawsuit is still pending, although there have been encouraging signs from the Ninth Circuit Court of Appeals and even the Supreme Court (in the most underplayed story of the year).

Marc Lifsher's new Los Angeles Times story places the spotlight on the restaurant's opposition to Healthy San Francisco--an innovative and groundbreaking effort to ensure universal access to care. (See a new one-sheet summary of Healthy San Francisco by the Kaiser Family Foundation.)

The article indicates that dozens of SF restaurants are now placing notices on menus, announcing additional costs--from $1 to $2 dollar flat fees to 1-4% surcharges--to help pay for the new health care requirements.

But the tactic, clearly designed to stoke public opposition to the law, may backfire:

* Of all the things that your dollars, it would seem that San Franciscans might think that a few extra dollars to go to the effort for universal health care is a good thing.

* The beneficiaries of the health care law are not faceless. They are the waiters and waitresses that diners interact with. And even for the kitchen staff--wouldn't you want the people handling your food to have health insurance? Especially since there is a correlation between being insured and health status?

* It's clear that some of the traditional arguments against employer requirements don't apply to San Francisco restaurants--people aren't going to go across the Bay Bridge to get a burger, or a fine dinner, simply to avoid a small surcharge. Rather, the minimum requirement helps level of the playing field between a coffee place that does provide health benefits, and one down the street that doesn't.

* The article quotes at least one patron that didn't mind the surcharge. So, if the surcharge is truly passed on to consumers, this undermines the restaurant's argument that the requirement will put cuts into their profits or put them out of business. They can't have it both ways.

Any health coverage expansions--from employer mandates to single-payer to hybrid "shared responsibility" plans--are going to ask employers who don't cover their workers to contribute more than they do now. It's an issue not just of financing, but of fairness--to the many employers who cover all their workers. It's also a practical issue: without a minimum contribution, policymakers fear "crowd-out," where those employers currently offering coverage drop it so their workers take advantage of a public program expansion.

Fast food and chain restaurants will eventually have to be share in the solution, rather than spending their time raising money against reform, pursuing legal attacks, and even trying to make political points on menus. But it looks like that may be a longer wait than what's at the trendiest San Francisco restaurant.

Labels: Employers, ExpandingCoverage, SanFrancisco

posted by Anthony Wright | Permalink | 10:31 AM


 

Supreme silence from the sultan of Sacramento...

Thursday, February 21, 2008

For all the handwringing on whether health reform would violates ERISA federal law, there's another positive signal today in this AP article:

The U.S. Supreme Court says a San Francisco program that provides health care to the uninsured can continue while a lawsuit challenging the initiative is pending.

Without comment, Justice Anthony Kennedy on Thursday refused a request by the Golden Gate Restaurant Association to halt the program while the 9th U.S. Circuit Court of Appeals considers its legality.

The appeals court earlier ruled that city officials could implement the program, dubbed Healthy San Francisco.

The first-in-the-nation initiative requires companies with at least 20 workers to provide health coverage or pay the city a fee to help offset the program's estimated $200 million price tag.

Let's remember, the lower court struck down the minimum employer contribution part of the Healthy San Francisco plan, due to concerns about ERISA.

But then the city not only appealed, but also sued to stay the decision--and the Ninth Circuit agreed, saying that the appeal had a strong likelihood to succeed.

For the Supreme Court to implicitly agree-is a positive sign. For this silent agreement to come from Justice Kennedy--the main swing vote on the Supreme Court--it is even a better sign.

There's no slam dunk on any of this, but for those who are *so* sure that ERISA prohibits any health reform at the state or local level, we have one really important Supreme Court Justice thinking it's not unreasonable for San Francisco to go ahead with their reforms...

Labels: SanFrancisco, YearOfReform

posted by Anthony Wright | Permalink | 3:06 PM


 

Balancing Hardships

Tuesday, January 15, 2008

Proponents and opponents of health reform point to the vast amounts of human suffering that will ensue should something not pass -- or pass. I have no doubt that both sides are correct, but I would point everyone to Pages 28-31 in the recent San Francisco decision, where the judges wrote eloquently about the "balance'' of hardships imposed various sectors under the Healthy San Francisco Program -- or lack thereof.

I'm going to summarize their words more bluntly, but you can read the more graceful version by clicking on either of the links posted above.

If Health San Francisco did NOT go forward:

• Patients who just started treating their diseases would stop going to the doctor, stop taking drugs, and risk death or serious illness.
• The city would incur costs -- as it does now -- because sick (and now, uninsured) patients would cram into the city clinics and public hospitals and the city would not have enough dollars from employers -- or other sources -- to help offset the costs for caring for the uninsured.
• For the "public interest"... well.... wouldn't you want to know the person who is handling your food is healthy?

If Healthy San Francisco DOES go forward:

• It would be a big administrative pain in the rear for businesses, and it'd cost them money because they'd actually have to provide health care for their workers.

This "Balance of Hardships" perfectly frames our remaining year(s) of health reform. Given those pros and cons, wouldn't you want health reform?

Labels: InTheNews, SanFrancisco, YearOfReform

posted by Hanh Kim Quach | Permalink | 10:30 AM


 

A shout out to the health nerds

Thursday, January 10, 2008

First thing's first -- if you want to see it for yourself, the Ninth Circuit's ruling to suspend the lower court Judge Jeffrey White's stay on the Healthy San Francisco Plan, click here.

The ruling is interesting in light of the work being done this year to reform health care and expand health coverage statewide -- in part -- through an employer mandate. In fact, when the ruling came down against the San Francisco plan right after Christmas, there was no shortage of Scrooges in the streets, praising the decision that would have left 26,000 middle-income San Franciscans uninsured.

(Background: Golden Gate Restaurant Association sued to prevent an employer-mandate piece of the Healthy San Francisco Plan from going into effect, saying the ordinance violated the federal ERISA law. ABX1 1, a measure that will be heard in the Senate Health Committee next week and has been agreed to by both the Speaker and Governor, contains an employer mandate as part of a package to extend coverage to more than 3 million uninsured Californians).

Reasons the Ninth Circuit ruled against the Restaurants and for the City:

• The ordinance does not require businesses to adopt any specific kind of health plan, it merely sets a spending threshold that employers would have to meet, therefore, it does not violate ERISA. (ERISA was intended to assure that employers would not have to contend with a hodgepodge of different benefit laws etc in each and every city, county, state they operated. This has nothing to do with levels of expenditures)
• If an employer does not meet the spending requirements, they pay money to the city -- again, with no reference to benefit structure of a health plan for which they will pay.
• The ordinance doesn't require employers who already provide coverage to provide certain benefits (thereby altering their ERISA plans.)
• Lastly, there is no additional burden to complying with the ordinance, as employers would be tracking this information anyway.

On top of the technical details, the court also found the hardships borne by San Francisco residents would be far greater than those borne by businesses. Approximately 20,000 San Francisco workers would be harmed, including "human suffering" -- contrasted with economic injuries.

While ABx1 1 is not exactly the same as the San Francisco ordinance, the arguments used by opponents against an employer mandate (which IS part of ABx1 1) are essentially the same. This ruling should put that hollering to rest -- until the next court ruling...

Labels: InTheNews, SanFrancisco, YearOfReform

posted by Hanh Kim Quach | Permalink | 6:23 PM


 

SF wins stay, employer contribution in effect, for now...

Wednesday, January 09, 2008

The Ninth Circuit Court of Appeals has ruled in favor of San Francisco, to grant a stay of the lower court decision to strike down the employer contribution of their Healthy San Francisco plan.

This means that San Francisco can begin implementing its Healthy San Francisco plan, including the employer contributions, while the case is fully heard and deliberated at the Ninth Court of Appeals. There's no guarantee that SF will win the final appeal (or appeals to the Supreme Court), but it send s a powerful signal. From the decisions:

In this case, we hold both that there is a “probability” — indeed, a “strong likelihood” — of success on the merits, and that “the balance of hardships tips sharply in . . . favor” of the City and the Intervenors. We further hold that the public interest supports granting a stay.

We're not done with this. The legal challenges for the San Francisco plan, and for state-based health reforms in general, are still ongoing. But this suggests there is a "strong likelihood" of defending local health reforms against these challenges.

Most of all, this is good news for the San Franciscans who can now get better access to care as a result.

Labels: SanFrancisco, YearOfReform

posted by Anthony Wright | Permalink | 1:39 PM


 

A potential San Francisco treat?

Friday, January 04, 2008

Promising news from the ERISA lawsuit on the Healthy San Francisco plan at the Ninth Circuit Court of Appeals. Yesterday, a three-judge panel ini Pasadena heard arguments about whether it should stay the ruling and let San Francisco proceed with the employer contribution of its new health plan.

So while no rulings were made, on the stay or the substance of the ERISA challenge, it seemed the judges poked holes in the logic of the opponents of San Francisco's health reform. Bob Egelko at the San Francisco Chronicle has the intriguing write-up.

Court gives San Francisco health plan a boost
Bob Egelko, Chronicle Staff
Writer
Friday, January 4, 2008

PASADENA--A federal appeals court boosted San Francisco's hopes Thursday of reviving its plan to extend health coverage to all uninsured residents and make employers share the cost.

Members of a three-judge panel of the Ninth U.S. Circuit Court of Appeals made it clear they thought U.S. District Judge Jeffrey White was on shaky ground last week when he struck down a key funding provision of the health program, which would require medium and large companies to offer insurance to their workers or pay a fee to the city.

Ruling in a lawsuit filed by the Golden Gate Restaurant Association, White said San Francisco was trying to require employers to provide a specific level of health benefits. That violates a 1974 law prohibiting state and local governments from regulating employee benefit plans, White said.

But San Francisco's lawyers argued - and the appeals court judges appeared to agree - that White had misread the law. The city says the law provides only that employers must spend a certain amount on health care, either in coverage for their workers or in payments to the city.

That's a crucial distinction under past U.S. Supreme Court rulings that have given states and cities some leeway to pass laws protecting their inhabitants' health and welfare, said Judge William Fletcher. If the city's interpretation of its law is correct, he said, "that takes away virtually all of Judge White's reasoning."

When Richard Rybicki, lawyer for the Golden Gate Restaurant Association, conceded that the city was reading its ordinance accurately, Fletcher said, "It seems to me your argument just disappears on you."

Rybicki argued that the San Francisco ordinance still intruded too deeply into employers' health care decision-making and would contradict Congress' goal of national uniformity in health plans. But Fletcher and the other two panel members, Judges Stephen Reinhardt and Alfred Goodwin, seemed skeptical.

The court gave mixed signals on whether it would grant the city's request for an emergency order suspending White's ruling and allowing the ordinance, including the employer fees, to be fully implemented during the appeal process.

But the judges' questions and comments during the one-hour hearing in Pasadena suggested that the court was prepared to interpret the 1974 federal law in a way that leaves room for universal, shared-cost health coverage at the state and local levels, in the absence of a national health care law....

For those who are supposedly so confident that any attempt at health reform will run afoul of ERISA (I'm looking at you, Chris Reed), this hearing should give pause that some judges who matter might not be so sure

There's no ruling to celebrate, and just like we said with Judge White's lower court decision, there's still a long way to go in the legal review of the San Francisco case, as well as statewide health reforms. But it's clear there's an opening, and the question is how big that opening is, and what is the right policy that is able to make it through.

The San Francisco Chronicle editorial board makes it clear why this legal inquiry is so important, well beyond the city's borders.

Labels: SanFrancisco, YearOfReform

posted by Anthony Wright | Permalink | 8:34 AM


 

Happy New Year..

Thursday, January 03, 2008

HEALTH ACCESS UPDATE
Friday, January 4th, 2008


A NEW YEAR BRINGS NEW EFFORTS AROUND HEALTH REFORM

• Governor, Speaker file initiative language to accompany reform package
• Lower court rules against employer contribution for Healthy San Francisco, although Appeals court sends promising signals
• Senate Health Committee to hear AB x1 1 (Nunez) on January 16th
  
  

In a typical year, Sacramento stands still the week between Christmas and New Year. Not so, in 2007, especially regarding health care.

The last Health Access Update reported from the Capitol (December 17th to be exact), when Gov. Arnold Schwarzenegger, Assembly Speaker Fabian Nunez, and a broad and diverse number of supporters were at a celebratory press conference right after the passage of ABx1 1 (Nunez/Perata) out of the Assembly. (Senate Leader Don Perata chose not to immediately hear ABx1 1, waiting until after the break as analysts looked at fiscal forecasts for the measure.)

If ABx1 1 (Nunez) is passed along with its accompanying ballot measure – which was filed last week – it would represent the largest public program increase in more than 40 years and would require all California businesses to contribute toward their workers’ health care. (Read a more detailed analysis of ABx1 1 here, and about its passage here. Ongoing updates will be posted on the Health Access blog.)

THE INITIATIVE

Last Friday, the Governor and Speaker filed with the Attorney General the initiative that accompanies ABx1 1. As previously agreed upon, the initiative contains some of the financing of ABx1 1. The initiative includes four financing components:

• $1.75 per pack tobacco tax;
• Minimum employer contribution of 6.5% of payroll (if payroll exceeds $15 million); 6% (if payroll is between $1 million and $15 million); 4% (for payrolls between $250,000 and $1 million); and 1% (for payrolls below $250,000);
• $1 billion from counties in return for the state assuming care of medically indigent patients;
• Hospital provider fee of 4%, which would be used to bring down federal funds to help increase Medi-Cal rates and partially fund coverage expansion.

The money that the initiative raises largely goes to expand public programs for lower income Californians -- both children and adults -- to provide subsidies for moderate income families, and to raise Medi-Cal rates and to fund some public health and prevention efforts. It also sets a standard for employer contributions to health care for their workers.

The measure also includes a $25 million loan to finance children’s coverage from January 2009 through June 2009, allowing children to continue to be enrolled in county programs until statewide coverage takes effect. Without this provision, the counties would run out of money and would likely disenroll children from coverage.

The initiative also contains various door-stop/triggers to prevent the program from creating a fiscal threat to the general fund. First, the Director of Finance, twice a year, would look into the state’s special health account to determine if there is enough money to run the program. If not, then he tells the Governor and Legislature, giving lawmakers a chance to do something about it. If the Governor and Legislature fail to act, then the law is inoperative and the reforms revert to the current status quo, in an attempt to calm the fears of those who have questioned whether the program might create too much of a strain on an already strapped state budget.

The initiative will likely emerge from the Attorney General’s office with a Title and Summary and fiscal analysis in the next month. The measure then heads to the Secretary of State’s office, who will certify the initiative and start the (less than) 150-day clock for signature gathering efforts to place the initiative on the November ballot.

LITIGATION ON HEALTHY SAN FRANCISCO

Other news broke over the holidays with potential but uncertain impact on health reform. A Bush-appointed San Francisco Superior Court judge, Judge Jeffrey White, struck down a key provision in San Francisco ’s near universal health care plan, which required employers to either provide coverage to workers or pay a fee that would enable the city to provide medical services to employees.

The decision says the San Francisco law would violate the federal ERISA (Employee Retirement Income Security Act). The federal law, passed in 1974, was meant to assure that mulit-state businesses did not have to contend with a hodgepodge of rules about benefits for each city, county, state they operated in. The city of San Francisco has appealed the decision to the Ninth Circuit Court of Appeals, which heard initial arguments yesterday.

The ruling creates a problem for the implementation of the Healthy San Francisco program, which moved ahead with the rest of the proposal with a rollout on Tuesday, January 1. The court decision, if left to stand, would force San Francisco to limit enrollment, which means that 26,000 middle-income San Franciscans (out of the 82,000 uninsured residents) will not be able to benefit from health care. While a financial hit, the employer assessment was not the dominant part of the funding: Employers contributions were expected to pay for approximately 19% of the city’s program.

PROMISING HEARING YESTERDAY: A three-judge panel yesterday heard arguments about whether the employer contribution piece of the Healthy San Francisco Plan should continue while the lower court decision is appealed. As reported in the SF Chronicle today, the comments by all three judges suggest that the lower court ruling may be overturned, and that the federal ERISA law does allow room for states and localities to construct health reform for their citizens.

Meeting the requirements of both health reform and ERISA has been an issue for health reformers around the country. Since the beginning of this year’s health debate, advocates and the authors have consulted with experts – including lawyers who helped write ERISA –to help prepare for such a court case against the proposal.

UNKNOWN RULING IMPACT ON ABX1 1

There are some similarlies between the statewide reform proposal, and city's effort. But the San Francisco health plan and ABx1 1 are not mirror images, therefore, any ruling on the San Francisco proposal won't necessarily have an impact on ABx1 1.

But perhaps most importantly, is a suggestion which the lower court judge gave into how an ERISA-compliant reform could be structured.

From Judge White’s conclusion:

The Court is not convinced that other alternatives for creating a program for
providing public health private employers into account in the form of tax
credits. are are not viable. Defendants propose an increased general tax
requirement, but state the unfairness of not taking existing health care
expenditures into account. Without wading into the legislative dominion, the
Court can envision such a tax program that takes existing health care
expenditures by private employers into account in the form of tax credits.

White’s suggestion parallels language in the initiative that was filed by Gov.
Schwarzenegger and Speaker Nunez:

19003 (a): On and after January 1, 2010, each employer shall pay a health care contribution equal to a percentage of wages paid to its employees during the calendar year. Each employer shall be eligible for a credit to offset the contribution by the amount that the employer expends for health expenditures for employees and their dependents during that same period.

It remains to be seen whether the SF health plan will advance or be impacted by the courts, but in absence of a definitive court ruling, many health advocates continue to seek to advance reform at the state and local level.

ABX1 1 IN SENATE JANUARY 16

As attorneys toil away in separate corners, the state Senate Health Committee is scheduled to hear AB x1 1 (Nunez) on January 16.

Senate Leader Don Perata, who has been supportive of health reform in the last year, has asked the Legislative Analysts' Office to perform an independent review of ABx1 1's impact on the state's general fund in light of the $14 billion budget deficit in the fiscal year.

The state Department of Finance has testified in hearings that the plan would have no impact on the state budget because it uses its own sources of revenue -- from employers, workers, the federal government, savings, providers and the tobacco tax -- to pay for itself and would shut itself off if it were found to have insufficient funds.

The Legislative Analyst is expected to have an analysis in the coming weeks.

CALL TO ACTION: Submit letters about ABx1 1 (Nunez) to the Senate Health Committee by January 10th to be reflected in the committee analysis. Health Access will post our Support (if Amended) letter shortly.

Sen. Sheila Kuehl, Chair
Senate Health Committee
State Capitol
Sacramento, CA 95814
FAX: 916.324.0384

Health Access will continue to provide updates on ABx1 1, the initiative and other health reform efforts, including late-breaking developments that will be posted on our blog, at:
http://www,health-access.org/blogger.html

To view other resources from the Year of Health Reform, visit our website, at:
http://www.health-access.org/advocating/2007_healthdebate.html.

You may also contact the author of this report, Hanh Kim Quach, at hquach@health-access.org.

Labels: Legislation, SanFrancisco, Updates, YearOfReform

posted by Anthony Wright | Permalink | 11:55 PM


 

Taking suggestions...

Wednesday, January 02, 2008

While Chris Reed of the San Diego Union-Tribune is so sure that the state health reform plan is going to be struck down because of ERISA, given the recent decision in San Francisco, the judge who made that decision isn't so sure. In fact, he proposes a structure similar to what the initiative filed last week proposes.

From Judge White’s conclusion in his opinion:

The Court is not convinced that other alternatives for creating a program for providing public health care are not viable. Defendants propose an increased general tax requirement, but state the unfairness of not taking existing health care expenditures into account. Without wading into the legislative dominion, the Court can envision such a tax program that takes existing health care expenditures by private employers into account in the form of tax credits.

From the initiative filed by Governor Schwarzenegger and Speaker Nunez:

19003 (a): On and after January 1, 2010, each employer shall pay a health care
contribution equal to a percentage of wages paid to its employees during the
calendar year. Each employer shall be eligible for a credit to offset the
contribution by the amount that the employer expends for health expenditures for
employees and their dependents during that same period.

There's no guarantees, but it seems that the initiative takes the judge advice--and let's remember this is one judge who takes a broad view of ERISA pre-emption.

Labels: SanFrancisco

posted by Anthony Wright | Permalink | 4:55 PM


 

Knowing where your food comes from....

In light of last week's San Francisco Superior Court ruling on the Healthy San Francisco plan, I think we should take take Michael Pollan's nonfiction hit The Omnivore's Dilemma a step further.

The Golden Gate Restaurant Association contested the portion of the Healthy San Francisco Plan which requires the city's employers with more than 50 workers to provide health coverage or pay an assessment to the city, which would then give employees access to the city's network of medical services. Healthy San Francisco aims to provide health coverage to the city's 82,000 uninsured residents. The GGRA won the first round, meaning that approximately 26,000 middle-income workers will remain uninsured -- and presumably many of those are also toiling over the range, serving up food, greeting guests and washing dishes.

The association's website claims it has more than 800 members. Clicking through, I'd say it included about 600 restaurants, including uniquely San Francisco gems like The Slanted Door, Green's and Citizen Cake and chain restaurants such as Hooters, Pasta Pomodoro and Il Fornaio.

The trend among the health conscious is knowing the origins of food: where it comes from, what impact its production had on the environment, whether it had to travel far to arrive at your table.

Let's make part of that "knowing,'' discovering whether the food is served by someone who has access to a doctor when they need it (and can afford it). And if it isn't? We have the ability to walk away.

Labels: Employers, InTheNews, SanFrancisco

posted by Hanh Kim Quach | Permalink | 12:45 PM


 

The actual impact of the SF ruling...

Friday, December 28, 2007

What's the impact of the court ruling in San Francisco?

As the San Francisco Chronicle reports today, the immediate impact is that Healthy San Francisco will not be able to extend to it full potential, restricting access for 26,000 middle-income San Franciscans. That's the unforunate human impact of the decision. Whether it has a long-term impact on the financing of the rest of the program has yet to be seen, but it's a concern.

But maybe not for long. There's no guarantee of what will happen on appeal. As the Workplace Prof Blog sees it, "I expect an appeal to the Ninth Circuit where all bets are off and panel composition will be key."

As for state health reform? A ruling on one type of health reform is a ruling on... one type of health reform. What was proposed in San Francisco is different in detail, structure, and scope from what is proposed at the state level.

It's not a surprise that a George W. Bush-appointed judge with a background as a corporate lawyer struck down a San Francisco ordinance, based on a ambiguous federal law that this very judge quotes is a "veritable Sargasso Sea of obfuscation."

Despite the fact that "the task of developing a clear rule to identify whether ERISA preempts a particular state law 'has bedeviled the Supreme Court'", this judge took an expansive view of ERISA pre-emption. But even in ruling against San Francisco and the labor unions who intervened, he keeps the door open, and proposed something that could pass muster:

He then describes the very structure in SB2/Prop 72 of 2004, and what is essentially what is expected to be part of the financing of AB x1 1: Assess all employers, but provide a credit/reduction for those who make health expenditures directly for their workers.

It's unfortunate that the decision will impact San Franciscans trying to get care, at least until the appeal. But it shouldn't impact state efforts, whether for AB x1 1 or SB840, and might even offer an opening...

(Largely cross-posted from a discussion at Calitics).

Labels: Employers, SanFrancisco, YearOfReform

posted by Anthony Wright | Permalink | 1:07 PM


 

Why employers matter...

Thursday, December 27, 2007

The San Francisco court decision and the ERISA issue in general raises the question: why do health reforms seek to raise money from employers, rather than other sources of funds? (The Sacramento Bee's Daniel Weintraub is like a broken record on this point.)

In front of the LA Times editorial board, Mayor Gavin Newsom gave a good answer a few months ago, in talking about the Healthy San Francisco program:

So $104 million's there; $56 million comes from individuals in point-of-service fees, which are these co-pays and monthly premiums based on ability to pay.

And the rest comes from — and here's the controversy, and this, there's always gotta be a controversy with health care — there's a mandate to businesses, starting with businesses with 50 employees or more. Incidentally, those represent, the mandate will represent only 13% of the businesses in the city, because 87% fall into the category of 50 employees or more or they fall into a category where they don't already provide a baseline of services. So you're affecting about 13% of businesses above 50 employees or more that aren't necessarily investing in the health care of their employees. It works out to a de minimis cost of the overall $196 million. It's about $28 million, the business mandate.

The reason we have a business mandate, again, is for no other reason, it's not intended for the money so much as to create a floor of expenditure. Here's the reason: I've got about 19 small businesses I've created, started restaurants and hotels. If the city said, as I have, that we're gonna take care of health insurance, I'd say fantastic. I'll dump all my health care; city picks it up. Then our uninsured population goes from 82,000 back to 190,000, 200,000, 300,000, and the system collapses. So we create a floor so there's no dumping out. And this is the controversy. The restaurant association, of which I'm a former member and large contributor with our nine restaurants, have sued us. And we'll see if they're successful. And if they are we'll have to be more creative.

AB x1 1 also doesn't raise very much new money from employers, but the employer contribution standard is an important component for practical reasons. The majority of Californians get coverage through their employer, or the employer of a family member. Even if we were to switch to another type of health care system, you would need some mechanism to keep that significant investment in the health system.

Mayor Newsom mentions the issue known as "crowd-out:" The more that a state or city offers coverage up the income scale, the more likely they might replace the coverage of employers that already offer coverage. In a world of limited resources, that'a problem, but can be solved by setting a minimum employer contribution.

Finally, the issue is fairness. Policymakers could simply have a flat tax that impacted all employers, regardless of whether they provide coverage. No one would question that arrangement under ERISA--but that would be grossly unfair to those employers who did offer coverage and were already paying for their workers, in essence asking them to pay more to help pay for the workers of those employers who don't offer coverage.

And that's the irony of the Golden Gate Restaurant Association's lawsuit. Despite their rhetoric, they aren't actually attacking employer contributions for health care. They are attacking the ability to provide some equity for employers who actually cover their workers.

And now, they is undermining San Francisco's important health program, and some of the uninsured that were going to be helped. Hopefully--appeals pending--not for long.

Labels: Employers, SanFrancisco, YearOfReform

posted by Anthony Wright | Permalink | 3:59 PM


 

An opening?

On his blog, the Sacramento Bee's Daniel Weintraub opines on the Judge White's decision on Healthy San Francisco.

In reading the decision, he notes something that I noticed as well: that even this George W. Bush-appointed judge, with his very expansive view of ERISA pre-emption, left the door open for state and local health reforms. He even suggested what he thought might pass muster:

"The Court is not convinced that other alternatives for creating a program for providing public health care are not viable. Defendants propose an increased general tax requirement, but state the unfairness of not taking existing health care expenditures into account. Without wading into legislative dominion, the Court can envision such a tax program that take existing health care expenditures by private employers into account in the form of tax credits."

Such a structure was exactly what was proposed in SB2/Prop 72 in 2004, and it's a version of what is being proposed with the financing to AB x1 1.

There's lots of ways to structure an employer contribution requirement, and Maryland was different than San Francisco, which is different from Massachusetts, which is different from SB2, which is different from AB x1 1.

Some legal experts believe that the Ninth Circuit has on-point cases that may lead this case to be overturned on appeal. But even this ruling provides an opening.

Labels: Employers, SanFrancisco, YearOfReform

posted by Anthony Wright | Permalink | 3:36 PM


 

When judges attack...

Wednesday, December 26, 2007

A marauding tiger may not be only bad thing to come out of San Francisco this week.

This evening, a Judge Jeffrey White ruled with the Golden Gate Restaurant Association and against San Francisco and a key part of the ordinance that created the Healthy San Francisco program. Here's the San Francisco Chronicle coverage.

We've outlined in previous posts about the line of reasoning about how health reforms might withstand an ERISA challenge. The question of that federal law's impact on state and local health reforms has split judges--such as the appeals court in Maryland--and it's unfortunate that this particular judge sided against San Francisco's important health reforms.

Both sides were prepared to appeal to the Ninth Circuit, and the city is expected to file their appeal on Thursday. The city should appeal: San Francisco has a strong case to make on behalf of its residents, to improve their health care system while giving employers different options to meet their obligations.

Some will over-read this decision, both its implications for health reform in San Francisco and California: This is far from the final word on health reform; it's actually just the first round.

First, there will be an appeal in this case. As for state reforms like AB x1 1 (or SB840, etc.), they have different structures than the ordinance in San Francisco, which had a different framework than previous efforts in other states and counties. A ruling about one does not necessarily impact the other.

The proposed health reform in the California legislature would continue to allow multi-state employers to have a national benefits package for their workers, which is the focus of federal ERISA law. Like other state reforms, it needs to be vetted by the courts, but with its specific language and specificity.

San Francisco should and must appeal; The efforts of California and other states must continue; What's the alternative? Health reform is too important and too urgent to wait for the federal government.

Labels: Employers, SanFrancisco, YearOfReform

posted by Anthony Wright | Permalink | 6:56 PM


 

A SFO-LGA cross country connection...

Thursday, September 13, 2007

The New York Times shines a national spotlight on the Healthy San Francisco program.

It shows that it is off to a good start...

Does San Francisco offer lessons for the special session? The article goes into all the ways that San Francisco is advantaged, including a relatively small uninsured population, and an already heavy investment in caring for them through a robust safety-net of clinics and hospitals. In other words, the opposite of California as a whole.

Yet even with this program--which is not coverage and does not offer access to coverage outside of San Francisco, they needed to take a second step--place a minimum spending requirement for employers, to prevent certain employers from abandoning their contribution to their workers' health care. The issue is called "crowd out."

Most employers provide health care, to attract and retain workers, and because it is expected. But if workers would get benefits anyway, why would employers spend the money to provide it? That means some employers would drop or scale back coverage. The issue is that the public program gets more expensive, since it is now covering more folks. It's not an issue if you can get enough money from the employer to actually pay for the care provided to his/her workers.

So when we hear of proposals to "replace" the employer fee in AB8 or the Governor's plan with another revenue source, the main issue is not some attachment to employer-based coverage; it's that you have to raise a lot more money to make up for it. There's also an equity issue, between those employers who provide coverage, and those who don't.

Healthy San Francisco is showing the way.

Labels: Employers, SanFrancisco, YearOfReform

posted by Anthony Wright | Permalink | 5:33 PM


 

A San Francisco treat...

Thursday, Au