Table of Contents

• Heath care reform: Is single-payer off the table?
• What's up with health care reform?
• How to get health coverage
• Health savings accounts haven't taken off too well
• New help for laid-off workers with COBRA premiums
• You can try these tips to control health care costs
• A bold experiment in San Francisco

About this issue

The articles in this special Health Action Issue of Consumer Action News were researched and written by Linda Sherry, Director, National Priorities. If you have comments or feedback, you can email Sherry at .(JavaScript must be enabled to view this email address).

Heath care reform: Is single-payer off the table?

Some health care advocates, experts and members of Congress have been making the case for single-payer health care coverage (government provided national health insurance). They call a single-payer plan the antidote to a U.S. private health insurance system riddled with anti-consumer practices, hefty premiums and lack of access to medical care.

Single-payer insurance (or universal coverage) is a system in which a public or quasi-public agency organizes the financing of health care, collects premiums or taxes from users, and pays for the delivery of care, which remains largely private.

Single-payer also appears to be preferred by a majority of Americans. In January, a New York Times/CBS poll found 59 percent of respondents are in favor of government provided national health insurance.

But current plans floated by President Obama and influential members of Congress do not favor single-payer.

According to the White House, "On health care reform, the American people are too often offered two extremes: government run health care with higher taxes or letting the insurance companies operate without rules. President Obama and Vice President Biden believe both of these extremes are wrong."

Montana Congressman Max Baucus, who has devised his own health care reform "Action Plan," noted recently that "single-payer is off the table."

Detractors of a single-payer plan have drawn the attention of a few commentators on CNN and the Fox News Network, who have picked up on arguments that single-payer is "socialized medicine."

To counter detractors, a grassroots response is growing. Protests from activists prompted the Obama administration to ultimately include two single-payer advocates in a White House health care summit in March. Rep. John Conyers, author of national health care legislation (HR 676), attended the summit along with a representative of the pro-universal health care group, Physicians for a National Health Care Program. Conyers is leading the charge for single-payer health insurance in Congress.

Advocates for national health care say that single-payer is being ignored in the debate in Washington, DC, despite evidence that it saves money, contains future spending, will include everyone and can help improve the economy.

The Physicians for a National Health Program make many compelling arguments for a national single-payer system. It says that eliminating private insurers and recapturing their administrative waste could in itself finance a single-payer program.

National health care supporters argue that the two entitlement programs Americans hold dear, Medicare and Veterans Administration health care, use similar models and are for the most part highly successful.

Filmmaker Michael Moore's documentary "Sicko" highlighted national health programs in Canada, France and the United Kingdom and convinced many viewers of the potential value of national heath insurance. Many conservatives and other supporters of the current privately managed health insurance industry denounced the film as sensationalistic.

Proponents argue that President Obama promised health care reform, but at the same time he has taken single-payer health care off the table. A study released in March by Fairness and Accuracy in Reporting (FAIR), a media watchdog group, found that in the week before Obama's health care summit the hundreds of stories on health care included only five presenting "the views of advocates of single-payer—none of which appeared on television." Most of the mentions of single-payer were in opinion columns written by opponents, said FAIR.

Single Payer Action is a grassroots group organized to advance the agenda. "Single-payer would make it unlawful for health insurance companies to sell health insurance the way they do now," said Russell Mokhiber, a Single Payer Action organizer (View Single Payer Action website). "That's why the industry demands that anybody who wants to be a player in Washington says the magic words—single-payer is off the table. Obama says it. Health Care for Americans Now says it. Senator Baucus says it. And the health insurance industry says it. We say the American people want it. Doctors want it. Nurses want it. And health economists want it."

Congressman Baucus says his own plan would ensure meaningful coverage and care to all Americans, but insists that expanded coverage include an emphasis on higher quality, greater value, and "over time" less costly care. Baucus also says he is committed to weeding out waste, eliminating overpayments, and designing a sustainable financing system that works for taxpayers as well as for the recipients and providers of health care.

Obama proposal

The Administration's plan states that "if you like your current health insurance, nothing changes, except your costs will go down by as much as $2,500 per year." Those without health insurance would be given a "choice of new, affordable health insurance options."

The Obama plan would require insurance companies to cover pre-existing conditions so everyone, regardless of their health status or history, could get benefits at "fair and stable" premiums. Currently, people with pre-existing conditions or chronic illnesses are out of luck unless they have continuous employee coverage. If they lose their jobs, they must keep that coverage by paying hefty COBRA premiums, and find another job with employee coverage within 18 months. (See story about COBRA developments.) Under current rules, no company that offers individual health insurance is required to cover pre-existing conditions.

A plan to tax people's employer-paid health care benefits has been proposed and is alarming many people. It would mean that the value of the employer-paid benefits would be added to the worker's taxable income, increasing his or her income taxes.

The concept was floated by Senator John McCain on the presidential campaign trail last year, and roundly rejected by Obama. But the idea has resurfaced as a way to raise tax revenues for health care reform and expand coverage to the uninsured.

President Obama's budget proposal sets aside more than $630 billion over 10 years as a down payment to expand coverage for working families. Obama says he will pay for health care reform by rolling back the Bush tax cuts for Americans earning more than $250,000 per year and retain the estate tax exemption at its 2009 level ($3.5 million), which will likely face opposition from conservatives.

Other aspects of the Obama health care plan include:

• A new small business health tax credit to help small businesses provide affordable health insurance to their employees.
• Lowering costs for businesses by covering a portion of the catastrophic health costs they pay in return for lower premiums for employees.
• Preventing insurers from overcharging doctors for malpractice insurance and investing in ways to reduce "preventable" medical errors.
• Requiring large employers that do not offer coverage to contribute a percentage of their payrolls toward employee health care.
• Establishing a National Health Insurance Exchange with a range of private insurance options as well as a new public plan based on benefits available to members of Congress that will allow individuals and small businesses to buy affordable health coverage.
• Creating a tax credit to lessen the impact of health care premiums on the needy.

Advocacy resources

To learn more about health care reform, visit:

• The Kaiser Family Foundation offers a wealth of studies, polls and commentaries from health care experts.
• FamiliesUSA. Everything you ever needed to know about the health reform debate, plus plenty of consumer education materials.
• National Coalition on Health Care. Labor, consumers, medical providers and faith groups working to ensure health care reform.
• Single Payer Action. A front-line fighter to mobilize action and keep single-payer on the table.

What's up with health care reform?

You hear the words "health care reform" a lot nowadays. It sounds like a good idea, and it sounds like policy makers are on the same page.

Unfortunately, this is not the case—reform ideas are all over the place. Here are just a few of the various agenda items: expanding coverage for the uninsured, lowering individual health care costs, reforming the health care delivery system, coverage for undocumented immigrants, balancing the federal budget and harnessing entitlement spending.

These are some of the policy concepts being floated in various health care reform platforms, including some contained in the Obama Administration plan:

• Expanding the current system of employer-based health care.
• Building a competitive government-run health plan to compete with private health insurance plans.
• Providing health insurance payment assistance to low-income, uninsured individuals and families.
• Mandated individual plans and tax incentives for individual insurance.
• Increased or reduced (depending on your political bent) regulation and oversight of the health care insurance marketplace.
• Insurance market reforms to promote national purchasing groups and other coverage expansion concepts.
• Tax policies that would raise more money for health care reform, such as taxing employees who have employer health benefits.
• Reducing overall costs through the use of improved technologies such as electronic health records and telemedicine.
• Ensuring the privacy and security of electronic health information.

How to get health coverage

Many people get group health insurance through their employers or membership organizations.

Millions of others are over 65 and are eligible for Medicare coverage.

But there are many more people who work for employers who do not offer health care, or who are self-employed.

It's estimated that 47 million people in the U.S. do not have health insurance.

Millions of workers don't have the opportunity to get health coverage. The Henry J. Kaiser Family Foundation's 2008 Employee Health Benefits Survey found that one third of U.S. employers don't offer health benefits.

At 13.2 million, people between ages 19 and 29 make up the largest percentage of the uninsured. According to a 2005 study by Health Affairs, another 16 million are underinsured because their insurance did not adequately protect them against catastrophic health care expenses.

Young people widely lack access to health insurance because many of the jobs available to young people don't offer health insurance, and if they do, the cost to the worker is too high.

What can you do if you don't have access to group insurance?

Join an organization

It can be a challenge to locate this kind of insurance, and certainly, not everyone is eligible to join organizations that offer group health insurance.

Members of AARP, for instance, can get group health insurance designed for people aged 50-64. The Writers Guild of America, which has strict guidelines for members, who must be professional writers, offers a plan to members. The National Business Association offers group plans to member businesses.

Type the words "membership benefits health insurance" in an online search engine to find more options. Check out all companies with your state insurance department. You can find contact information for your state at National Association of Insurance Commissioners website.

TIP: When investigating plans, make sure you ask how the rate will change after the first year.

Individual insurance

It can be very difficult to find an individual insurance policy with premiums you can afford that also provides decent coverage. If you are healthy, you don't smoke, and you aren't looking for a lot of preventative care coverage, you can probably find a policy that would cover serious medical emergencies. You can lower your premiums if you look for a plan with a higher deductible. If you do this, remember that you will have to pay your own health expenses until you meet the deductible.

A number of insurance quote services, such as ehealthinsurance, will give you price quotes based on your individual situation. If you lie or omit your health history on these applications, coverage and claims could be denied in the future, even after you have paid substantial premiums.

Individual policies often exclude the very care that prompts people to seek them out: pre-existing conditions, current illness and maternity care. The number of individual health insurance policies that does not include maternity coverage has risen dramatically in recent years.

In California, Assemblyman Hector De La Torre of Los Angeles County has introduced a bill (AB 98) that would require all health insurance products regulated by the state Department of Insurance to include maternity benefits.

Governor Arnold Schwarzenegger vetoed a similar bill authored by De La Torre last year as well as one introduced in 2004 by former state Senator Jackie Speier, who was elected to Congress in 2007.

Medicaid

Medicaid is available only to certain low-income individuals and families who fit into an eligibility group that is recognized by federal and state law. Medicaid does not pay money to you; instead, it sends payments directly to your health care providers. Depending on your state's rules, you may also be asked to pay a small part of the cost (co-payment) for some medical services.

To find the agency that administers Medicaid in your state, go to State Medicaid Agencies website. Some medical providers will help you apply for Medicaid.

Children's health care

For little or no cost, the public Children's Health Insurance Program (CHIP) pays for doctor visits, prescription medicines, hospitalizations, and much more. Most states also cover the cost of dental care, eye care, and medical equipment. The states have different eligibility rules, but in most states, uninsured children 18 years old and younger with family incomes of up to $34,100 per year for a family of four are eligible. For more information about the program, call 877-KIDS-NOW (877-543-7669) or visit the federal government web site Insure Kids Now. During its renewal this year, the program that provides health coverage for children and pregnant women was expanded. This year's reauthorization of the Children's Health Insurance Program abolished the five-year waiting period for legal immigrant children and pregnant women who enroll in Medicaid or CHIP.

Undocumented immigrants

About 64 percent of illegal immigrants nationwide are uninsured, according to the Washington-based, Center for Immigration Studies (CIS). A number of states ensure that certain undocumented immigrants (usually including pregnant women) are entitled to health care through the Medicaid system and through local government programs. However, these programs are experiencing deep cuts in states like California due to the economy. To find out how to access care, visit a community walk-in clinic, or call your state's Medicaid agency. Many community-based clinics and faith-based medical providers will provide care for undocumented people with no questions asked.

Local walk-in clinics

According to the U.S. Department of Health and Human Services (HHS), in many areas there are federally funded clinics where you can go for care.

Federally funded health centers offer care even if you have no health insurance. You pay what you can afford, based on your income. The care provided at health centers varies, but many provide checkups, treatment, complete care for pregnant women, immunizations and checkups for children, prescription drugs and mental health and substance abuse care.

Some are completely free for certain individuals while others have an income-based sliding fee scale.

HHS offers an online directory to help you find a clinic near your home.

Medical schools

While they are sometimes not widely advertised, large medical teaching and research institutions often have low-income clinics. Staffed by professors and medical students, these clinics also can help you find access to financial assistance and benefits such as Medicaid, as well as their own discounted payment programs and local charity care.

Medical trials

For those who suffer from a pre-existing condition or chronic illness, access to medical trials can open up a world of free care. However, most trials are based on comparing real drugs and treatments to placebo treatment, meaning that you may end up going through treatment and find that you were part of a control group that did not actually receive the drug or treatment being tested.

Clinical Trials.gov is a web site (http://clinicaltrials.gov) that provides information about available trials.

It is also helpful to identify large research institutions (such as Stanford University in California, Johns Hopkins in Maryland, or Sloan-Kettering in New York City) and call a few to ask how you can find out more about their trials.

Veterans

Of the 25 million living veterans, almost three of every four served during a war or an official period of hostility, making them eligible for Veterans Administration (VA) benefits. In addition, another huge population that includes certain family members or survivors of veterans, may be eligible for health benefits. The VA offers a searchable online directory.

Health savings accounts haven't taken off too well

Health savings accounts (HSAs) are self-directed savings accounts that allow you to set aside money for health care. The accounts have income tax advantages. Contributions are deductible from your income and the interest (or other earnings on the assets) in the account is tax-free.

To qualify for a health savings account, you must be younger than 65 and you must enroll in a high deductible health insurance plan (HDHP). You can have an HDHP without establishing a savings account, or HSA, but you cannot have a HSA without first enrolling in a high deductible health insurance plan.

Consumer demand

Health savings accounts have been available since 2004. They were designed to give uninsured consumers new health care options and help control health care costs. However, they are not particularly popular with consumers.

The plans are complex, which may be a deterrent to eligible individuals. Consumers who establish a HSA are solely responsible for ensuring that contributions do not exceed the annual maximum allowed amount or they may face penalties.

In most cases, the plans require consumers to pay for drugs and other medical services themselves, without the cost caps and smaller co-pays that exist in most managed care plans. (In some cases the HDHP may provide some network cost savings on these expenses.)

Employees with chronic illnesses who take several medications may meet their deductible very quickly.

When you reach age 65 and enroll in Medicare, you can use a pre-existing HSA to pay Medicare premiums, deductibles, co-pays, and coinsurance under any part of Medicare. If you have retiree health benefits through your former employer, you can also use your account to pay for your share of retiree medical insurance premiums. The one expense you cannot use your account for is to purchase a Medicare supplemental insurance or "Medigap" policy.

Once you turn age 65, you can also use your account to pay for things other than medical expenses. However, if you use the money for non-health related expenses, the amount withdrawn will be taxable as income.

Eligibility

Once you enroll in a high deductible health insurance plan (HDHP), you are eligible to open a HSA. The account does not need to be provided by the insurer, and in fact many companies that offer the HDHPs do not offer HSAs. Your bank, credit union and some brokerages may offer HSAs.

The HDHP must be your only health insurance coverage. To qualify, you can't be covered by any other medical insurance or employer-provided health insurance. You can still qualify if you have dental, vision, disability and long-term care insurance.

If your employer offers a high deductible insurance plan, you may be able to deposit money into a HSA on a pre-tax basis. If you open a HSA on your own, you can deduct your deposits when you file your income taxes. Contributions may be made at any time of the year in one or more payments. Balances remaining in a HSA at the end of the year roll over to the next year.

Contributions to your health savings account, except employer contributions, are subtracted from your taxable income. This means you do not have to pay income taxes on the money deposited in your HSA as long as your contributions are within the allowed amount -- even if you don't itemize your deductions. For 2009, individuals can contribute up to $3,000. Families can contribute up to $5,950.

If your spouse has health care insurance, but you are not eligible to participate, you can establish your own HSA. The accounts always are individual accounts—you cannot have a joint HSA.

HSAs are similar to individual retirement accounts (IRAs) because they must be established as custodial accounts so that an independent third party, such as a bank or brokerage house, can track your deposits and withdrawals and report them to the Internal Revenue Service (IRS) for tax purposes.

Coverage

Unfortunately for those with chronic or current illnesses or diseases, HSA compatible health insurance plans (HDHPs) typically exclude or limit coverage of pre-existing conditions.

Some insurance carriers pay for preventative care services before the deductible has been met. This can be helpful in staying healthy.

Nuts and bolts

Most high deductible insurance plans will issue you an insurance ID card. Show the card when you go to the doctor or visit the pharmacy to fill a prescription. Your medical provider will file a claim with the insurance company so that you get any network discounts and the amount you are billed will be applied to your deductible.

You control the money in your HSA. You can reimburse yourself at any time for medical expenses you paid with non-HSA funds. The amount of the HSA withdrawal must match the exact amount of the medical charges.

Some custodians offer a HSA debit card. Others allow you to write checks from your HSA account.

Because you are able to claim certain tax advantages, you must keep records to support all withdrawals.

If you deposit more than allowed in your HSA, take out the excess amount plus any income it earned before it is time to pay taxes for the year. Otherwise you could be liable for a 6% tax, plus any income tax you would normally owe on the amount.

More information

HSA Educator

Internal Revenue Service (IRS) Publication 969.

Pros and cons of HSAs
Potential advantages	Possible disadvantages
Money you place in your HSA may be deducted from your taxable income.	You cannot establish a HSA if your employer offers a health plan (unless the plan is a high deductible health plan).
Allows you to set aside and budget money for health care costs.	Requires that you can accurately budget for your health care expenses—you may be unprepared for unpredictable needs.
Works best for healthy people with healthy dependents.	Having to set aside money in an HSA might cause consumers to avoid seeking preventative treatment.
You can shop around for care based on quality and cost.	Information on cost and quality can be difficult to obtain.
Money in your HSA rolls over from year to year if you don't use it all.	Withdrawals for nonmedical expenses before age 65 trigger income taxes and a 10 percent penalty.
Interest and investment earnings on the account are tax free.	Your heirs must pay income tax on the money in a HSA.

New help for laid-off workers with COBRA premiums

With massive job lay offs across the country, many people face difficult questions not only about how they will replace lost income, but also how they can replace the health care coverage they lost with the job. Many people who lose health insurance once the job is gone have the choice to extend health coverage at their own expense—but many avoid doing it because of cost.

Now help is available to many people laid off during a period between September 2008 and December 2009. Because of widespread lay offs, Congress has expanded the Consolidated Omnibus Budget Reconciliation Act (COBRA) program to include assistance so that COBRA premiums are more affordable for people who lost their jobs. The government will cover 65% of the premium.

The American Recovery and Reinvestment Act of 2009 (the stimulus package) expanded eligibility for COBRA for people who lose (or lost) their jobs in the current economy and the law provides a premium reduction to qualified individuals. This assistance can be a lifesaver if you qualify, because continuing health insurance under COBRA is typically very expensive and may be unaffordable, especially if you continue to be unemployed.

If you were laid off by your employer on or after Sept. 1, 2008, through Dec. 31, 2009, you had health insurance, and you elect to continue COBRA, you may be eligible to pay only 35% of the amount you would normally pay for your COBRA coverage. The subsidy is available only if your adjusted gross income is less than $125,000, or $250,000 for married couples who file jointly.

If you lost your job during this time frame but didn't elect COBRA, you have 60 days to elect the plan and be eligible for the new subsidy. Your former employer's plan administrator must send you a notice of your eligibility to elect COBRA and to receive a premium reduction. The 60-day clock starts ticking from the time you are notified by your former employer about the changes.

If you believe you are eligible, but you didn't receive this notice, or you have moved and your former employer doesn't have your new address, contact your old employer directly to ask about the eligibility extension and getting the premium reduction.

What is COBRA?

The right to extend health care coverage under COBRA is a law that allows ex-employees to continue their health coverage for a limited time, usually up to 18 months, if former employees elect to pay the premium. The former employee usually pays the entire premium, plus a 2 percent administrative fee.

COBRA may also provide retirees, spouses, former spouses, and dependent children the right to temporarily continue health coverage at group rates.

COBRA is not available if your former employer has fewer than 20 employees or if your employer went out of business completely and no longer offers employee health coverage.

A law similar to COBRA covers federal employees. If you are laid off a federal job, contact your personnel office for more information on temporary extensions of federal worker health benefits.

The COBRA choice

People with pre-existing medical conditions or chronic diseases are better protected in obtaining care for such conditions if they elect COBRA coverage, especially if they have good prospects for finding another job with employee health coverage within 18 months.

Under COBRA, your health insurance company cannot exclude coverage for any pre-existing condition. On the other hand, virtually every individual health plan now sold will exclude pre-existing conditions—the very reason people with past, current or chronic illnesses find health insurance so valuable.

In addition, it may be cheaper to cover your dependents under a COBRA plan than to find a comprehensive individual policy.

State provisions

Some states have laws that require smaller companies with fewer than 20 employees to offer COBRA-like extensions. Some states, like California, are proposing to broaden and extend health coverage for some workers who've lost their jobs. The Kaiser Family Foundation's State Health Facts.org provides information on all state health related laws. Check to see what protections are available in your state.

Resources

The Department of Labor's Employee Benefits Security Administration and the Internal Revenue Service are two government agencies that will provide advice and guidance for the provisions of the COBRA assistance program.

If you have specific questions about your situation and how the new COBRA new rules apply to you, call an employee benefits advisor at 866-444-3272.

The Department of Labor has set up a special web page to provide information about the program at www.dol.gov/COBRA. It will be updated as necessary with new information about how to apply for COBRA and the premium reduction. You can also sign up for email updates.

You can try these tips to control health care costs

Health care inflation in the U.S. continues to spiral out of control. Total health care spending last year represented 17 percent of the gross domestic product (GDP). Containing medical costs and eliminating wasted care is central to many health reform policy platforms.

Employer health insurance premiums jumped five percent last year - double the rate of inflation, according to the Henry J. Kaiser Family Foundation Employee Health Benefits Survey. The annual premium for an employer health plan covering a family of four averaged nearly $12,700. The annual premium for single coverage averaged more than $4,700.

The recent Health Care Value Comparability Study by the Business Roundtable found that rapidly escalating health insurance premiums are having a profoundly negative impact on businesses. Ralph Neas, CRO of the National Coalition on Health Care, said recently, "The health care delivery system is actually harming the ability of American corporations to compete effectively in the global economy."

While health care consumers can't stop rampant health care inflation, we can at the very least try to contain our own health care expenses whenever possible. Because so many of us are covered by managed care plans, we have lost sight of what medical procedures cost, and rarely, if ever, challenge the amounts that providers bill to our health plans.

But when faced with paying for medical care out of pocket, many consumers become very interested in price. A niche industry is evolving to help consumers compare prices, and use the power of information to negotiate better rates for medical procedures and common preventative tests.

Cutting costs

Here are some things you can do to cut medical costs for you and your family:

• Schedule preventative visits to your doctor at regular intervals. Between visits, keep notes about things you would like to ask your doctor, and take these notes with you to the doctor's office. While there, make sure you obtain all necessary prescriptions, referrals and vaccinations so you don't have to go back for additional visits.
• If your doctor wants you to come back for a follow up visit, ask if it is really necessary to come in person, or can you follow up by phone.
• If your doctor suggests that you need a non-urgent procedure, ask for information about it and say you need some time to think. Take a week or so to research the suggested treatment using WebMD or another trustworthy health web site. Compare costs for the procedure at local providers by using Health Care Blue Book or New Choice Health. The added information about the treatment and its price will help to inform your decision.
• Review billing statements from medical providers and your health plan to make sure there are no errors.
• Notify your health insurance plan if you find billing errors. You don't want erroneous charges to count toward your annual or lifetime coverage caps.
• Appeal unfair decisions by your health plan. Document everything, send appeal documents by registered mail, and follow through to the bitter end, which may ultimately involve your state insurance department, if you are not satisfied with the insurer's decisions.
• Ask your doctor if it is appropriate to substitute generic drugs for name-brand medications. Many chain stores now offer very low prices, as little as $4 for a three-month supply, on many generics.
• Exercise on a regular basis and eat a balanced diet full of healthy foods including lots of veggies. Limit alcohol, red meat and snacks and candy that contain artificial ingredients, colorings and a high proportion of fat per serving size (junk food). Don't smoke cigarettes and regularly get a good night's sleep.
• Protect yourself from injury by wearing your seatbelt while driving, a helmet for biking and other sports that might result in accidents, and look both ways before crossing the street. Catastrophic injuries have caused some families to go bankrupt.
• If your health plan offers classes in ways to improve your health, take advantage of them. Many plans also have a "nurse line" you can call about non-urgent health care questions.

Emergencies

In a life-threatening emergency, seek immediate attention by calling 911 or going to the emergency room at your nearest hospital. But don't use the emergency room for non-urgent medical problems during regular business hours—call your doctor for an emergency visit. Most doctors' offices will fit you in and the cost will be a lot less.

If at all possible, get to the emergency room yourself without calling an ambulance. Unless you are in critical condition, ask a family member or friend to drive you to the emergency room. Ambulance transport is not free and you are responsible for the bill.

Even so, it can be tough for non-medically trained persons to judge a medical emergency. When in doubt, seek immediate attention by calling 911.

A bold experiment in San Francisco

In 2006 San Francisco created the Healthy San Francisco program, making San Francisco the first city in the nation to provide health care services to all uninsured residents. Enrollees in the Healthy San Francisco program are required to pay income-based participant fees.

As the first city to provide services for all uninsured residents, San Francisco serves as a testing ground for health care reform.

The program was challenged in court by a local restaurant owners' association on the grounds that it violated the Employee Retirement and Income Security Act of 1974 (ERISA), which prohibits state or local governments from regulating employee benefit plans, including health insurance. The restaurant owners were successful initially, but they lost when the U.S. Ninth Circuit Court of Appeals allowed the program to stand. The plaintiffs have said they will ask the U.S. Supreme Court to review the case.

Massachusetts and Vermont also require employers to provide or help to finance health insurance, but only the San Francisco program has been challenged.

The San Francisco program uses a concept called "medical home" which could become a key element in broader health care reform. Enrollees choose a medical home (a clinic or participating health care provider organization) from among participating providers, and that provider is responsible for assigning a physician and coordinating all of the individual's health care.