The best health care plan

Pub date June 27, 2006
SectionEditorialSectionNews & Opinion

EDITORIAL The health care model that’s been established, largely by default, in the United States is an utter mess. Most working people get their insurance through their employers. That means people who have jobs that don’t provide insurance are out of luck, and people who don’t have jobs are out of luck, and the self-employed are stuck with crazy bills, and small businesses are getting hit harder and harder with rising insurance rates that they can’t afford.
It’s a ridiculous way to handle health care: In most other western democracies, everyone is part of a national health care program, and under the best systems, the government is the single insurer and pays all the bills.
Among other things, that prevents the sort of crisis that San Francisco faces today, where the large numbers of uninsured residents have no choice but to seek care at the overburdened San Francisco General Hospital. That leaves the taxpayers on the hook for more than $100 million a year.
For businesses, particularly small businesses, that scrape and suffer to provide health insurance for their workers, the system is fundamentally unfair: Those companies pay twice, first for their own employees, and then again in higher taxes to cover the costs of the uninsured. Businesses that can well afford health insurance (the Wal-Marts of the world) but don’t pay are forcing others to cover their costs.
In a perfect world, with national health insurance, this wouldn’t be an issue. But it’s almost impossible for a single city to implement a single-payer system — which is why Mayor Gavin Newsom is struggling to present a functional health plan, and why Sup. Tom Ammiano’s employer mandate plan is absolutely necessary.
But the small business advocates who complain about the burden of paying more than $100 a month for each uninsured employee have a point, too — and this entire plan ought to be linked (at least in the long run) to Sup. Aaron Peskin’s proposals to change the city’s business tax.
Newsom’s dramatic announcement last week of a complex plan to cover all residents won overwhelmingly favorable press coverage. But so far, the plan itself is little more than a glorified press release. There are a lot of devilish details, particularly when it comes to funding.
There’s no new money in the mayor’s plan. He argues, correctly, that San Francisco currently spends $104 million on health care for the city’s 82,000 uninsured, and shifting that money into a city-run health care program will underwrite a significant amount of the cost. But that money can’t just be moved like a chess piece — it’s part of the San Francisco Department of Public Health budget, and if everyone does not sign up for the new program and very sick patients (including, say, undocumented workers who don’t understand or fear enrolling in the city plan) keep showing up at General, there won’t be enough money to go around.
There’s also the very real prospect that some unscrupulous employers will simply quit paying health insurance premiums and dump their employees into the city plan. That would overwhelm the program and push it quickly toward financial ruin.
So the mayor’s plan has no chance at success unless Ammiano’s employer mandate passes, too. The Ammiano plan would offer additional funding for the program by requiring that employers either provide private health insurance or pay into a city pool — and would prevent businesses from tossing their health expenses into the city’s lap.
Ammiano’s plan isn’t perfect — no employer-based plan ever will be. The health insurance requirement would hit all businesses with more than 20 employees, and that might be a bit low. The plan already has some progressive gradations (companies with more than 100 employees would pay a higher fee), but linking the costs more directly to the size of the business (in other words, hitting the large outfits — which can well afford health insurance — a bit harder and giving more of a city subsidy to the smallest companies) could help ease the burden on struggling merchants.
But in the end, his plan — which would have no impact on employers who already offer health insurance to their workers — is crucial to any effort to get the uninsured into a decent health program (and to end the stiff taxpayer subsidy for companies that don’t provide insurance). The supervisors should approve it.
Still that’s not the end of the story. At the same time that Ammiano’s addressing health care, Peskin has floated a proposal for a new gross receipts tax on local business. Here’s the way to proceed: The supervisors need to fund a complete study of how much gross revenue local firms take in; write a new tax that allows the city to eliminate the payroll tax; add a progressive gross receipts tax; and use the next tax policy to help deal with the costs of health care. Big, rich companies pay a lot (enough to help subsidize the citywide health plan). Small firms pay less (and the reduced tax burden helps offset the costs of paying for health insurance). In the end, San Francisco would be the first US city to launch a progressive system for providing health insurance to all. SFBG