By Sarah Varney February
22, 2019
SAN FRANCISCO — Sandra Yamileth Lopez
works at one of San Francisco’s most celebrated bakeries, Tartine. She fled
horrific violence in Honduras and applied for asylum in California. She can
work legally but, as for many new immigrants, it will be years before she
becomes eligible for Medicaid or federal health insurance subsidies.
In the meantime, she enrolled in
Healthy San Francisco, a pioneering program that guarantees health care to any
uninsured city resident. Lopez can live her life again, she said.
“I had a lot of recurring dreams about
what had been happening,” said Lopez. “I was also not able to relax. So,
doctors gave me medication to help me sleep and to help me relax with my anxiety.”
Healthy San Francisco launched in 2007,
under then-Mayor Gavin Newsom, years before the Affordable Care Act and at a
time when universal coverage was an audacious — and radically liberal — goal.
Partially funded through employer fees,
Healthy San Francisco is a reorganization of the city’s public health system.
Patients were directed away from expensive and overburdened emergency rooms and
into primary care clinics. They can get visits to specialists, prescription
drugs and, perhaps most important, protection from massive bills should they
need emergency care.
Although it may seem simple and obvious
now, said Dr. Alice Chen, chief medical officer and deputy director for the San
Francisco Health Network, turning a public safety net that rescued people in
crisis into a proactive, coordinated system was a revelation.
“We took the existing organizations
that provided care, made it into a system, and then actually created an
interface for patients who were uninsured and reached out to them and said,
‘Come on in, come in and use the system of care,’” Chen said.
After the major provisions of Obamacare
went into effect in 2014, most Healthy San Francisco patients enrolled in
Medicaid or bought subsidized private plans.
But about 13,000 remain: those who earn
too much for public programs but still can’t afford private insurance, and
people like Juan, who are undocumented and barred from federal public
assistance. Juan, who asked us to use only his first name, has been recovering
from a heart attack under the watchful eye of a cardiologist.
He takes a number of prescription drugs
that he otherwise could not afford. But here’s the dilemma: He’s covered only
inside the city limits of San Francisco — it’s not portable health insurance.
Juan, who works in a local warehouse, wants to move to San Diego to care for
his aging mother, but then he’ll be out of the program and unable to afford his
medications.
“Some of them are over thousands of
dollars a month, and if I don’t have that coverage in San Diego, I would have
to pay for it,” he said. “And if I don’t take that medication, it could be
life-threatening.”
About 3 million Californians remain
uninsured. About half of those lack legal status like Juan, and the rest cannot
afford the sky-high cost of American health care.
Fury over those costs, even for those
with insurance, has energized Democrats who want the U.S. to have universal
health coverage, like all other industrialized nations. But there are many
variations: single-payer, “Medicare-for-all,” plans that would largely do away
with insurance companies or employer-based coverage, and others that would
simply regulate them more closely.
Now that the former mayor of San
Francisco has become governor, Newsom said he wants to make California a
testing ground for universal coverage.
“Premiums are going up, deductibles are
getting higher, people are feeling stress and anxiety about what’s happening,
or not happening, federally,” Newsom said. “And they’re concerned that things
will get worse, not necessarily better, in the medium term, and a lot worse in
the long term.”
Newsom has asked the Trump
administration to allow California to pursue a single-payer system. Since
that’s unlikely to happen, he’s pursuing other options by creating what he says
is the nation’s largest prescription-drug purchasing pool to negotiate drug
prices, restoring the individual health insurance mandate, allowing
undocumented young adults up to age 26 into Medicaid and giving state subsidies
to 250,000 more middle-income Californians.
“You look around the rest of the world,
they’re just rolling their eyes,” Newsom said. “Higher life expectancy, they do
chronic disease management better than the United States, for roughly half the
price. You look at quality indexes, we drop to 37th in the world in
our quality index last year, below Cuba, and Costa Rica.”
He added, “This is ludicrous, and it’s
incumbent upon governors, mayors to take the lead in the absence of the federal
government doing its job.”
And that’s happening across the nation.
In Washington, Democratic Gov. Jay
Inslee has proposed a low-cost public health plan to compete with private
insurers on the state insurance exchange. In New Mexico, Democrats are sorting
out how people without insurance could buy in to Medicaid.
And in New York City, Mayor Bill De Blasio
is promising health care to undocumented immigrants and those who can’t afford
insurance.
“There’s enough people in this city who
don’t have any health care coverage to fill the entire city of Milwaukee, or
the entire city of Baltimore. That’s just a vast number of people,” he said.
It’s a total of some 600,000 New
Yorkers.
De Blasio recruited Dr. Mitch Katz, the
public health mastermind behind Healthy San Francisco, to build a similar
program in the city’s five boroughs. City officials plan to pump more than $100
million a year into the city’s financially strained public hospitals and
clinics and actively enroll the uninsured into a program called NYC Care.
That includes struggling young people,
like freelance musician and composer Andrew Sharkey, who has gone untreated for
Crohn’s, a serious bowel disease. He dropped his coverage in 2015.
“I just didn’t know where the money was
going to come from. I was working two jobs. They were both part-time so that
they didn’t have to pay into my insurance,” said Sharkey.
Under de Blasio’s plan, Sharkey would
have a regular primary care doctor and treatment from specialists and access to
prescription drugs.
Word about NYC Care is already
spreading among the more than 300,000 undocumented immigrants in the city, like
Antonio, who asked us to use only his first name. He thinks de Blasio’s plan
would simplify his life, allowing him to focus more on his health and work, and
less on the endless paperwork that comes with being uninsured.
“Oh my God, that is going to be a great
change for everyone,” said Antonio. “Now when I go to an appointment, I need to
run around from social workers, to organizations to find ways to reduce those
bills.”
Americans already pay for undocumented
immigrants when they come to the emergency room, said Mayor de Blasio.
“Let’s face it, we kind of kid
ourselves in this country about the reality of health care. So right away we’ve
got 12 million, maybe even more, undocumented folks who are part of the fabric
of the United States of America, and who need health care because they are
human beings,” he said. “But, in all of our policymaking, we deny their
existence. This is the greatest ‘don’t ask, don’t tell’ you’ve ever seen.”
De Blasio added, “We should have
universal health care nationally, we should have single-payer, we should have
‘Medicare-for-all,’ but in the absence of that, health care has become this
luxury item for so many people.”
Universal health care polls well with
American voters, but the Trump administration said if it became a national
policy, it would consume the federal budget.
“It’s fiscally unsustainable,” said
Seema Verma, administrator of the Centers for Medicare & Medicaid Services.
“But to make matters worse, it would destroy Medicare for the seniors who spent
their whole life paying into it.”
And some Democrats are voicing warnings
of their own. Former Vermont Gov. Peter Shumlin was forced to abandon his
attempt to bring single-payer to Vermont.
“What I’ve realized, and I think a lot
of legislators did, too, was, ‘Hey, if we don’t get costs under control first,
instead of getting that premium increase in the mail, you’re going to get a tax
increase passed through your legislature on an annual basis,’” Shumlin said.
“And there aren’t very many politicians from any party who want to be raising
taxes at the rate of our current health care inflation.”
“PBS NewsHour” producers Jason Kane and
Kira Wakeam contributed to this report.
This story was produced by Kaiser Health News,
an editorially independent program of the Kaiser Family Foundation.
Sarah Varney: svarney@kff.org,
@SarahVarney4
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