Corey Johnson

NYC looks to San Francisco as a model for universal health care

New York City officials are looking at implementing single-payer health care, although the model they're looking at is San Francisco, which enacted a program that is actually neither a single-payer system nor health insurance but rather universal access to health care.

William Alatriste for the New York City Council

Shortly before his election to New York City Council speaker, Corey Johnson floated the idea of municipal single-payer health care in multiple interviews, including with The New York Times and the Village Voice. Implementing that system would pose a hefty task for Johnson and for the city as a whole, as well as a fundamental question: Could it work?

The answer depends in part on whether the city plans to pursue a full-fledged single-payer model, which experts say is all but impossible, or some kind of scaled back version to expand health care coverage. As of now, city officials are looking to pursue the latter option.

A true single-payer system means that a single entity covers the cost of all health care. Everyone pays into a single plan run by the government, which in turn is the only provider of coverage paying claims. In New York City, as in any other municipality or state, this would entail the elimination of all other private or public health plans. Anyone currently buying insurance or getting it through their job would need to give it up and go on the publicly run plan.

To achieve this, the city would need Albany to ban private insurance providers from doing business within its borders. A slew of federal regulations also prevent the city from making changes to Medicaid and Medicare, leaving other payers in the system as well. Neither of these address the total cost of implementing the system either.

For these and other reasons, New York City will likely not go in that direction. Johnson has begun early talks with key players in this process, including Mark Levine, chairman of the City Council’s Health Committee. Levine told City & State that while nothing is off the table, officials have looked to San Francisco as a model, which enacted a program that is actually neither a single-payer system nor health insurance.

“I think it would be more accurately described as universal access to health care,” Levine said. “We sure can do a lot more to ensure that every New York City resident has access to health care.”

In 2007, San Francisco began a program called Healthy San Francisco, which could be described as a universal health care program. The program, which is available to uninsured city residents, offers affordable access to care at many health clinics and hospitals across the city. Since it only applies in San Francisco and only within a limited network, enrolling in the plan is not the same as having health insurance. In short, going to any hospital outside the city limits would mean that person would have to pay completely out of pocket. Instead, the program provides universal access to health care within the city’s borders.

Healthy San Francisco is funded through the city’s general fund, co-payments from participants that vary based on income and a tax on employers who don’t offer health insurance to their workers. And it is open to undocumented immigrants who are unable to get Medicare, Medicaid or any federally subsidized insurance from the Affordable Care Act. The program was spearheaded by Dr. Mitchell Katz, who recently took over as the head of New York City Health + Hospitals.

Katz told City & State the Healthy San Francisco model could work in New York City, but will face political challenges, such as where to get the required funding. He said the program would have been far harder to implement if San Francisco had not imposed a tax on employers who did not offer insurance. Such a tax in New York would require approval from Albany, where the Republican-controlled state Senate generally opposes tax increases.

Practical and logistical obstacles would have to be overcome as well. First, New York City has nearly 10 times the population of San Francisco. In fact, New York City has as many uninsured people as San Francisco has total residents. At its peak, the program only covered 60,000 people, a far cry from the needs of New York City.

According to 2016 census data, the vast majority of New York City residents already have health insurance, with about 43 percent of New Yorkers covered by public health insurance like Medicaid or Medicare. But roughly 664,000 people in New York City lack insurance, or 7.8 percent of the population. Immigrants make up two-thirds of the uninsured population and 25 percent of noncitizens lack coverage.

Johnson, the council speaker, isn’t the first person to call for single-payer health care – or something like it – in New York City. Anthony Weiner made it a key part of his campaign for mayor in 2013, a race he ultimately lost to Bill de Blasio.

Weiner’s plan didn’t actually constitute a true single-payer system either, but more closely resembles a public option – an insurance plan that is publicly run and funded. With a public option, the government could theoretically use its bargaining power, as the federal government does with Medicare, to negotiate lower health care costs. And unlike a single-payer system, use of that plan is not compulsory. It instead competes against other insurers in the marketplace.

Weiner’s particular proposal laid out the framework for a publicly run health insurance plan funded by the city that would cover city workers and retirees as well as undocumented immigrants, with the potential of eventually opening up to everyone.

Bill Hammond, the health policy director at the Empire Center for Public Policy, said New York City could create a public option safety net to cover those who don’t have insurance, including undocumented immigrants, which would address the city’s needs without taking on the costs of insuring the entire city. The city could pay for this through a combination of premiums, taxes and the reallocation of money in its budget.

But Hammond said a public option isn’t necessarily the best route for the city to go, and it could wind up costing both the city and taxpayers a lot of money. “None of this would be easy, politically or otherwise, and inevitably there would be winners and losers,” he said.

Katz added that he would support efforts, including a public option, that get more New Yorkers on insurance. He said that it would also help the city’s struggling system of public hospitals that he oversees, which has a deficit that is approaching $2 billion.

The public hospitals Katz oversees don’t turn anyone away regardless of insurance or immigration status, so it acts as something of a safety net for those who need it. But often, health care costs come straight out of the pocket of the hospital, since they get little to no insurance reimbursement and many of their patients can’t afford to pay. Katz said more patients with insurance would be a boon for his hospitals. He would even support money in the city budget being shifted away from New York City Health + Hospitals in order to fund a public insurance option.

“I always believe that you should give the person the right to choose,” Katz said. “So I think that it is much better to give people insurance and let them choose and let the dollar follow the person than to require that people seek care as indigent people.”

Any action the city takes could be moot if single-payer health care passed at the state or federal level. In Albany, Assemblyman Richard Gottfried introduced single-payer legislation that would create one public option and ban the sale of private insurance unless it offers additional coverage not included in the state plan. He has been trying to get that through the state Legislature since the early 1990s. Gottfried declined to comment for this story, but told City & State previously that “no New Yorker should go without health care or have to suffer financially to get it” and that single-payer health care is the best way to achieve that goal.

Back in the five boroughs, Levine said the City Council is still looking at its options and trying to figure out the best way forward. In addition to Healthy San Francisco, he also mentioned building on the Action Health NYC program, a one-year pilot to connect undocumented immigrants to health services. The pilot ended in June 2017 with no additional funds to continue it. Levine said the goal ultimately is to provide universal access to health care like preventive and primary care, not just emergency care. In the long run, Levine said, this would save the city money.

“It feels like the building blocks are there,” he said.

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