San Francisco to Offer Care for Every Uninsured Adult
SAN FRANCISCO — Since contracting polio at age 2, Yan Ling Ho has lived with pain for most of her 52 years. After she immigrated here from Hong Kong last year, the soreness in her back and joints proved too debilitating for her to work.
That also meant she did not have health insurance. Not wanting to burden her daughter, who was already paying her living expenses, Ms. Ho delayed doctors’ visits and battled her misery with over-the-counter medications.
“Sometimes the pain was so bad, I would just cry,†she said. “I didn’t know what else to do.â€
Last month, unable to bear her discomfort any longer, Ms. Ho went to North East Medical Services, a nonprofit community clinic on the edge of Chinatown, and discovered to her delight that she qualified for a new program that offers free or subsidized health care to all 82,000 San Francisco adults without insurance.
It amazes me to realize that, in the world’s greatest country, there are people — ordinary, everyday people, not just the people who slide under society’s skin and get blamed for stuff they don’t actually cause, like the homeless, who live on the fringes of society, or immigrants, who have taken their chances, leaving their homes, or any other undesirables — ordinary upstanding individuals like you or me, who are barred from obtaining regular medical treatment because they do not have private medical insurance.
It’s not a new realization by any means. I have long known it; and we hear it frequently, as Americans debate the issue and as we debated national health insurance here at home. But it’s not often that it comes home to me. After all, I live in a society where there is no income tax at all, but where the taxes we do pay nevertheless manage to provide us with universal access to basic health care. We have clinics in almost every community, and we have public and private hospitals, so that almost all of us can obtain some measure of health care.
Now this is crucial for me. I belong to a family that is relatively uninsurable. Unless we want to sell our cars and mortgage and remortgage our homes, the fact that our fathers all died before their 60th birthdays, from various chronic or non-communicable illnesses makes it virtually impossible for me and my cousins to get private insurance. Oh, I have coverage. But it’s group insurance, and it’s tied to a place of work. I wanted to be able to have a more flexible work situation. One of these days I would like to write full time, be self-employed as it were. So I applied for Bahama Health, which is friendly and warm and fuzzy and all that, and which made me think that it was the biggest group insurance in the country, but it turned me down.
In the USA, I would be uninsured. And this is unfathomable to me. If our small nation, the size of a flea on the American elephant, can provide universal access to basic health care to all of its citizens, its immigrants, and even its tourists, I cannot for the life of me comprehend the reasoning behind it. After all, this is the nation that prides itself on its democratic principles and sets itself up to be the monitor of the free world. I can’t see what principle of democracy is served, however, by excluding huge numbers of people from accessible health care.
In San Francisco, the city government is making its own decision about this idea.
The initiative, known as Healthy San Francisco, is the first effort by a locality to guarantee care to all of its uninsured, and it represents the latest attempt by state and local governments to patch a inadequate federal system.
It is financed mostly by the city, which is gambling that it can provide universal and sensibly managed care to the uninsured for about the amount being spent on their treatment now, often in emergency rooms.
After a two-month trial at two clinics in Chinatown, the program is scheduled to expand citywide to 20 more locations on Sept. 17.
Whether such a program might be replicated elsewhere is difficult to assess. In addition to its unique political culture, San Francisco, with a population of about 750,000, has the advantages of compact geography, a unified city-county government, an extensive network of public and community clinics and a relatively small number of uninsured adults. Virtually all the city’s children are covered by private insurance or government plans.
Now this — the fact that the programme may not be replicable beyond San Francisco — is another thing I find remarkable. The USA, we’re told, is a federation, a place where the federal government has to balance its power against the state governments. It’s a system that sounds pretty good on paper, most of the time. The states control a number of different things, like whether they execute people and how they do it, what kind of education system they provide, at what age people can drink liquor, how people can get married and to whom, and, presumably, health care. And there’s apparently a growing grass-roots movement demanding access to basic health care for all, especially given the fact that the most influential generation of Americans in our time (the so-called Baby-Boomers) is aging. But this movement is being blocked. In the USA, that great democracy to our north, it would seem that the major opponents to healthcare, whether it be state-wide or federal, is the insurance industry.
This should come as no surprise. The USA is a capitalist nation, and insurance companies are capitalist empires. While they appear to be fatherly and nurturing and friendly, they all too often bear elements that, in any other industry, would scream “scam” writ large. Don’t get me wrong. Insurance works best when it’s dealing with things — house insurance, car insurance, property insurance — all these make sense to insure. I don’t mind paying a fairly reasonable premium to help me out when bad things happen to my possessions. Even life insurance makes some sense; it’s not designed to help me, after all, but to keep me from being a burden to people I love, to help cover funeral expenses and so on. Insurance of these things makes sense.
But health insurance? I can’t help thinking it’s the biggest scam there is.
If you’re in the business of health insurance, forgive me, but here’s why I say that. Most companies refuse to insure people who are likely to claim on their insurance, like the elderly, or people with a history of chronic diseases, or people who (like me) come from a family where people have a history of chronic diseases. If they don’t drop you, your premiums go up. So the healthy get insured, and happily pay their bills, while the unhealthy can’t.
Now here in The Bahamas, while that’s an issue, it’s not as bad as we think it is; even the uninsured can get basic health care here. We Bahamians, this little black country, have figured out how we can cover everybody with basic health care with the non-income taxes we pay. In Nassau, particularly, our HIV patients receive treatment. All our mothers are entitled to pre-natal and post-natal care. Our elderly get taken care of. Even our tourists, whether they are insured or not, get to use our hospitals and clinics. And we never grow tired of complaining how our illegal immigrants can find all the health care they want or need — a fact, by the way, which I believe is a strength of our society and our government, not a weakness.
Because, contrary to what the federal and state and county and city governments of every part of the USA seem to think — except for, apparently, San Francisco — I happen to believe that people are more important than things. I don’t believe that my health, or the health of any other human being for that matter, is a commodity that can be valued by employers or insurance companies and abandoned when it the profit margin grows too narrow.
It would appear that this is a peculiar idea. It would appear that capitalism leaves very little room for people when money is on the line. The San Francisco initiative is being challenged by an employers’ federation. There are laws, apparently, that determine what “benefits” employers can offer, and how; and it would appear, further that health care is a “benefit”. Not a right.
A final financing mechanism has placed the program in legal jeopardy. To make sure the new safety net does not encourage businesses to drop their private insurance, the city in January will begin requiring employers with more than 20 workers to contribute a set amount to health care. The Healthy San Francisco program is one of several possible destinations for that money, with others being private insurance or health savings accounts.
Late last year, the Golden Gate Restaurant Association challenged that provision in federal court, arguing that it violates a law governing employer health benefits. A judge has scheduled a hearing for early November.
I’ll say it again. I don’t mind paying car insurance, life insurance, or house insurance for peace of mind. I don’t even mind paying for health insurance, if it means that I can qualify for more sophisticated or daring treatment, should I ever become very ill. But what I cannot comprehend is the idea that I should pay health insurance simply to be seen by a doctor at all. I do not believe that my health is a commodity that the “market” — any market — should determine. That’s what I elect my governments for.
Not, apparently, in the great democracy of the United States of America, where the greatest medical system in the world is accessible only to those who can pay. American governments, apparently, view the health of their citizens as just another thing, to be bought and sold and valued by an industry that has no real accountability to the citizens they “serve”.
So hats off to San Francisco. And hats off to The Bahamas, to all the politicians through the ages who made it a priority for all Bahamians and residents and visitors to gain access to medical treatment no matter what their status.
{ 18 comments }
Hmmm . . . sounds like you’ve just unmasked the myth of American “democracy.” We Americans pay a lot of lip service to it but . . . alas . . . when it comes to walking the walk, we often do quite poorly. Congrats to the good folks in San Francisco for actually trying to take those ideas seriously. I hope this initiative succeeds.
Dear Nicolette:
When did society change from being grateful for the new discoveries in medical care to feeling that it is their right to it without taking responsibility for getting insurance themselves etc?
I understand that the destitute cannot buy insurance so let’s take them out of the discussion for the moment.
Rick.
If you could explain to me why BASIC health care (not modern miracles, but the ability to, oh, get seen by a doctor when you have the sniffles) isn’t a right maybe I could engage with that question. But what I’m concerned about is that Americans don’t, among all the “rights” they do have, have the right to see a doctor if they haven’t bought insurance for themselves.
Insurance would make a whole lot more sense to me if people who actually needed it in the screwed-up world of buying good health could actually obtain it. I can’t. If you could explain that to me I might be more inclined to discuss.
If I were American and self-employed and I paid my taxes and was not destitute I would find it difficult to get insurance because of my family’s medical history. I happen to be fortunate to live in a country that takes care of my basic needs despite the odd fact that because I’m more likely to die younger than other people I am less likely to be able to obtain insurance.
It’s not a question of my living up to my responsibilities. It’s a question of my being excluded from the opportunity to shoulder them in the first place. Explain that, please.
How does this make sense?
You seem to have taken a remark about the general situation as a personal attack. That was not my intention. Sorry.
I was not discussing your personal issue. I also have a friend in a similar position. Those are the anomalies and deserve consideration.
The question I raised was when society changed from paying its way to expecting services as a right?
I also am not aware of the allegation that the average American cannot see a doctor if they have the sniffles.
Hope you can respond to my question.
Actually, Rick, you caught me when I was recovering from the flu and musing on the fact that if I didn’t live in The Bahamas, if I lived in the USA, I probably wouldn’t have gone to a doctor at all because I probably couldn’t afford to — or if I had, I wouldn’t have bought the required course of antibiotics that helped speed my recovery. This is a flu that has a propensity to turn into pneumonia and require hospitalization, something that people who are inadequately insured will avoid. It is a flu that (unnecessarily, IMO) can therefore spread more quickly and more virulently than it needs to because of the unavailability of universal health care.
I do not believe that my position is an anomaly. I do not think that health care is an option or a service. Health is not an individual issue. Poor health can spread, and is doing so in the USA as we speak; communicable diseases don’t get treated, much less prevented, because good health has been categorized as a “service”, a “benefit”, and not a right. The fact is that where health care has to be bought, poor health grows more prevalent. That this is happening in the USA currently is not something that is widely publicized, but it remains a fact.
The current number of Americans without health insurance, from Time Magazine of September 17, is 47 million (last year it was 44.8 million). This is not an incidental problem. These people cannot easily be dismissed as irresponsible, destitute, or greedy. They are in all likelihood normal people, some of whom, like me, are uninsurable. Their health should not depend on the whim of some company whose fundamental purpose is to increase profits. That it does indicates to me that their society has failed them. After all, all societies collect taxes. One of the things those taxes should be used for is to improve the basic health of the society and its individual citizens. Whatever frills people want to pay for on top of that is up to them. However, in the USA, access to doctors — and more especially to competent or good doctors — depends on whether one has insurance or not. It’s unconscionable.
Obviously you and I are on opposite ends of this spectrum, but I would recommend you read Crisis of Abundance, Rethinking how we pay for healthcare by Arnold Kling.
There was a time when 100% of the people in the world had no health insurance as the idea did not exist. It has always been a service.
As I mentioned in an earlier response, there are always anomalies and these deserve consideration.
Let’s take NMC for example. Less than 50% of our employees take up the benefit of health insurance and we pay 50% of the premiums for individual or family coverage, yet I see the flashy cell phones, spinners for the wheels etc. It’s inexplicable to me.
Why should you and I fund their health care services from our tax dollars if they become ill?
Because their health is our health. I could make the same argument for books and education, but the point is that the health of a society and the advancement of a society is measured by the health and education of its individuals. I don’t think that either is optional. Other stuff, yes, but other people’s ill health affects yours and mine.
Not to belabour this Nicolette but I think we are near enough on care for the indigent, where we differ is personal responsibility for those that can purchase insurance.
The main issue with health insurance today is it is no longer insurance. We expect to get every service imaginable under our insurance contract. No other insurance policy works that way.
According to Kling, health insurance was a boon for doctors as they no longer had to worry about getting paid. The bad thing is, we really do not know what the care is costing, so why should we care? After all, that’s why we pay insurance right?
It’s not a simple matter.
I’m not sure we differ on personal responsibility as much as you think, either. I suspect we share the same basic concept. Where we differ is on what is meant by “personal responsibility” and what is meant by “care for the indigent”. From the discussion so far, I think we are pretty close on the basic issues, which are:
Some health care should be provided (by the state? I would say so, but I don’t know what you would say here, as you would prefer to reduce all state-sponsored services to the barest minimum) for people who cannot purchase insurance.
Individuals should take responsibility for additional health insurance, should they want or need it.
Where we differ is on the drawing of lines.
With regard to those people who should have automatic health coverage, you categorize those people as indigent.
As I am not indigent, but cannot purchase insurance, and as all the members of my father’s family are in the same position, I don’t categorize those people as indigent.
I also include the self-employed, the people who have chronic diseases (or people who are healthy, but whose parents or siblings have chronic diseases), the elderly, and people who are already ill. All these people who are not in a position to buy insurance, as they have been excluded by insurance providers from access to reasonable insurance policies.
Further, we disagree on what should be provided. You say that we don’t know what the care is costing. I argue that in many cases the cost of health care is grossly inflated because of insurance.
In countries where the state covers the cost of health care, health care is not as expensive as it is in countries where insurers cover that cost. On the one hand you might argue that the costs are kept artifically low by state-sponsored care. I could argue that insurance has made the costs unnaturally high. The issue isn’t simple, true. Nor is it black-and-white.
As I have said at least twice, cases like yours are the anomalies and deserve some attention. How they would receive cover is the question that needs debating.
Maybe government does need a fund for that.
With regard to the indigent, I would prefer the government issue vouchers to them for their insurance rather than providing the service themselves.
You will get no argument from me that insurance has made health care expensive. It’s because we do not see the charges coupled with the fact that we believe health insurance is something other than it is. We see it as cost protection. Insurance does not work that way on any other commodity.
Rick, I’m appreciating this debate because it’s useful to have perspectives on two far sides of the issue.
My other beef with health insurance — earned from my experience with elderly relatives who paid health insurance all thier lives — is that individual health “insurance” coverage is automatically cancelled when people turn 70. If they have made no claims during their insured period, they lose all their premiums, and are not covered at a time when of course they are going to need insurance the most.
That is what I think is unconscionable.
I’m not sure I agree that there should not be an end to coverage.
Fact is we are all dying and if we are lucky enough to get to 70, evidence is that the treatment provided for catastrophic illnesses at that age does not really prolong life.
In addition, the cost of treating the elderly is tremendous.
Also, I look at health insurance at this stage of my life as a bit of protection for my wife and children should I become seriously ill. I do not see it as offsetting the cost my routine doctor visits.
Maybe my perspective will change if I get older and want to live another day? Who knows?
But this is my problem. Health “insurance” is not that — it’s a scam to make companies richer.
If health care costs were kept realistic — and we don’t really know what that realism is, but the difference between the medical costs in the USA with brand-name drugs, insurance coverage, infinite health-care options, and so on and that in many other countries, ours included, suggests that the reality is probably more than it is in state-subsidized places and less than it is in “insurance”-controlled places — then perhaps people could make realistic choices.
I have a serious problem with the concept of health care as a commodity. I believe that people should have the option of obtaining reasonably priced medical attention for as long as they live. One result of prosperity is that we live longer. But that prosperity does not benefit us; it benefits insurance companies who collect our wealth while we are healthy and refuse to return it to us when it is no longer profitable to insure us.
The lie sold by insurance companies is that my money will help me later when I need it. But it isn’t true; when I become “uninsurable” my premiums are not returned to me. I would do far better to invest my money in the stock market or in a bank so that when I get sick (after I turn 70) my investment still stands. Health insurance companies do not serve the interests of public health; they serve the pockets of their shareholders.
I wouldn’t have an issue with the return of premiums to people who have not collected major sums on their insurance when the coverage is cancelled. I would be far less hostile to the concept of “insurance” if that happened. But I’m afraid that I regard health insurance as a scam that was invented to make companies richer. You have said nothing to convince me of anything different.
Help me out, Rick. I’m trying to engage sensibly with this, but your points aren’t convincing me; the problem with the lack of insurance for the elderly isn’t just the problem of the elderly, but of those who have to care for them — their children and their other relatives. How is this at all helpful for society, for individuals, for anybody other than the health insurance company?
Nico:
You seem to want the state (all taxpayers) to assume what is our individual personal responsibility – to care for our family as best we can.
I think you should save your money and not pay insurance if you feel that they are simply ripping people off.
How do you determine insurance is just a scam?
Do you know what net returns health insurance companies realise?
What is a reasonable return in your mind?
Do you know that if Ontario Canada keeps going the way they are going with the cost of their single payer government health care system, in something like 25 years, every dime raised in taxes in Ontario will have to be used to pay for their health care system? There will be no money left for any thing else.
There is no easy answer.
I think you misunderstand me, Rick, in so far as you misinterpret what I want from the state.
These are my assumptions for the basic requirements of governing and maintaining a functional modern society, in which strangers live and work very closely together with all the attendant risks.
Public health is a real issue. What you regard as individual personal responsibility is, to my mind, obsolete. When we were living as relatively isolated family units, whose connections were to people who we knew all our lives, perhaps your understanding of individual personal responsibility vis a vis our health was reasonable. However, modern societies learned, after centuries of dismal public health and widespread epidemics (the bubonic plague, yellow fever, smallpox, malaria, etc), that the responsibility for public health could not be left in the hands of individuals, who are far more likely to make choices based on their own personal interests, not on the greater public good.
Individuals haven’t changed. Public health is still a challenge. A person’s health is not just his or her business. Today we’re facing different potential epidemics, without realizing it. From obesity and the various chronic conditions that accompany it to HIV-AIDS to the secondary infections that have survived and grown resistant to our antibiotic regimes — TB, pneumonia, and dangerous flus — an individual’s health impacts the group.
I believe that the state has to assume responsibility for maintaining the health and the equilibrium of the group. That element is absent from your discussion, except when you admit that the state may have a responsibilty for those who cannot care for themselves. When the state abdicates its responsibility — as it has in the USA, whose system is fundamentally flawed, and whose system, because of its position in the world, affects global health through the development and export of treatments, drugs, and lifestyles — public health, not private health, is affected.
I want all taxpayers to have their taxes used in such a way that public health is maintained and regulated. And I want all taxpayers’ money to be used in a way that reflects contemporary needs. This discusion was not even valid half a century ago; no one disputed the importance of the state in health care. Every modern state provided polio vaccines, smallpox vaccines, etc. Public funds were used to find ways to eliminate the worst communicable diseases. Birth control was in the public arena in many states, because population control is a state issue, not a personal one.
Today, public health is threatened in a number of different ways, but it has not yet been transformed into a private matter. I agree with you in so far as I agree that each individual has a responsibility to his or her own health. Where I disagree is in the assumption that an individual’s health is the entire responsibility of the individual.
I didn’t get the flu three weeks ago from myself, for instance. I got it treated quickly, because I live in a country that provides me with the means to do so, by providing clinics and a public hospital that does not require me to have either insurance or money to obtain treatment in a timely fashion. Because I got it treated quickly, and because I took a course of antibiotics, my flu didn’t turn into pneumonia, as it has done in many other people. On the other hand, I have friends and relatives who soldiered on through their own attacks of flu, and who ended up spreading the illness to other people, some of whom ended up in the hospital. The result of that is not a private matter. Those who were working did several things: one, they may have infected their workmates; two, they put their employers in a position of losing their labour while they were in the hospital, and potentially of losing their labour for good; and three, they put their families — who didn’t give them the flu — in a financial position that they had never anticipated, even with personal insurance coverage.
What I am adamantly opposed to, Rick, is the idea that health is a private matter, something optional that can be maintained through individuals’ personal choice. I don’t see how that argument can be sustained, unless individuals walk around in bubbles and never have contact with other people. I have observed again and again, even in our society where we have clinics and a public which provide health care for the uninsured and which cannot refuse care to people who cannot pay, that those people who do not have insurance do not practice preventative or early health care. They wait until they can physically do no more, and that places a strain on every health care agency, from the government to the insurance companies.
On the one hand you talk about how disgraceful the insurance companies are and suggest government should take care of it? I’m confused.
Do you think my point about the cost of OHIP in Ontario is valid?
Then you talk about public health and epidemics or potential epidemics?
Seems to me you are mixing apples and oranges.
What am I missing?
What is confusing about suggesting government should take care of health? I elect my governments. When they behave disgracefully, they answer to me. I have some say about what should happen in health care when it is controlled by government than when it is controlled by private enterprise.
The same is not true of privately owned and controlled insurance companies, who answer to shareholders only. If I am a client and not a shareholder, I have no say.
With government, I am a client AND a shareholder.
Re the cost of OHIP: I don’t know what it is, because you haven’t given me details, so I can’t say whether it’s valid or not. I do know I was insured by OHIP when I lived in Ontario, and was satisfied then. I can’t speak for now. I need more information to make a conclusion about your position.
I’m not clear how I’m mixing apples and oranges, though. For me, health is a public concern, not a private one; it’s all apples.
Or all oranges.
I’m open to adjusting my opinion, but I need something concrete to sway me. I can’t just take your word; you have a political position that shapes your opinion (as have I). But I have concrete reasons for holding my own opinion — some of them are my own experience, which I’ve shared with you. If you would provide me with concrete examples of how and why health insurance is better for the general public than public health service, then I could talk about the validity of your position. But so far all I have is opinion.
Unfortunately the government can’t do everything as the great experiment in Russia showed us.
Sure they should be able to mobilise people in the event of an out break etc., but that is quite different than heath care. That’s the apples and oranges I’m talking about.
Too bad you didn’t join us for the Nassau Institute symposium in June.
But if you can take the time to review this link – you can view the PowerPoint presentation while listening the the audio, you will have lots of evidence.
http://blogbahamas.typepad.com/blog_bahamas/2007/08/lessons-from-gl.html
The charts about the growth of expenditure for health care in Ontario is nearing the end.
Hope this helps?
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