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The Health Care, Gay Marriage Re-run


Quick quick. What’s the connection between gay marriage and universal health care? The answer is that they’re the two political issues that San Francisco and Massachusetts agree on, while the rest of the nation thinks they’re nuts! But are they?
In both places, the executive leadership, Governor Mitt Romney in Mass and Mayor Gavin Newsom in SF, have been somewhat forced to lead the charge on those issues in order to avoid being impaled by their left flank. And both men are regarded as being way too out there for their national parties to recognize that they exist.
Romney of course has got the hardest line to tread on the gay marriage issue – it was forced on him by the courts and he obviously could do without it. He personally has to deal with his Mormon upbringing – the LDS excommunicate gays when even the Catholics don’t. Then there’s the conservative Republicans who hate gays at the urging of James Dobson, Jesus, Ecclesiasticus or someone else more than 2000 years old. Those are the ones who will (likely not) vote for him in the primaries in 2008. But then he has to deal with his current constituents, so it’s a little tricky because he has to talk out of both sides of his mouth.
Newsom took a good look at the national polls, which show that young people don’t care much about the gay issue and that even oldsters are caring less. As his national ambitions can wait until those youngsters get older, he figured that out that neutralizing his pesky left flank was well worth the flack he’d get for the gay marriage stance from the befuddled wuses that run the national Democratic party. Getting lots of publicity was a bonus too, and now he has no effective political opposition on his home turf and is regularly touted for national office.
Interestingly the homes of these two ambitious politicians, Massachusetts and San Francisco, are also the only places where there’s anything approaching a serious political discussion about universal health care. Earlier this year Romney signed a universal coverage bill in Massachusetts which has somewhat mythical accounting behind it, but is based on an individual mandate. Despite a symbolic veto which he knew would be overturned, Romney’s bill also includes a teeny employer mandate. If employers don’t cover their employees, then they get fined a derisory amount (which is far less than the cost of providing said benefits). But the main funds for the new system come from a combination of diverting Federal funds and charging individuals for their coverage.

San Francisco’s plan is coming from the other end. It started with an employer mandate similar to the one narrowly voted down in a state initiative (Prop 72) in 2004, and is adding an individual mandate to that. The basic problem is that San Francisco (like every other city and county in the nation) spends a fortune as a health care provider paying for services for the uninsured at its county hospital, and getting basically no money from either the uninsured or their employers – and most uninsured are working, as you all ought to know by now.
So like Massachusetts, San Francisco wants to take that public money it’s already spending and combine it with some new mandates/taxes on those employees and employers mooching off the system by not providing insurance for their employees. The city can then spend the money providing health services to all the uninsured in the numerous city facilities where they’re already getting care. Presto; that equals universal coverage!
Of course the fine print involves that extra spending. I castigated Romney in an earlier piece for saying that you could get to universal health insurance without a tax increase. At least one end of that sentence is a lie, unless of course you are parsing the word “tax” in true Clintonian fashion. In the version of the San Francisco plan to which Newsom eventually agreed the deal is fairly split between employers and employees.

The projected cost of the plan — initially estimated at $200 million per year — would be paid for with the $104 million in city funds that officials say already goes to provide care to the uninsured, plus $56 million in contributions from consumers, with most of the rest coming from employers.

So we’re talking about adding around at least $100 million in spending for about 85,000 people or a little over a $1,000 a year each. To me that’s an acceptable number, but if it’s coming out of the wages of the employees and a payroll tax on their employers, then it’s the difference between staying in business and going home for many low wage industries, as my article about a local restaurant, Incanto, demonstrated.
You can probably expect a significant amount of creative accounting in San Francisco’s small business sector as this law’s enacted. My bet is that many restaurants and auto repair shops will magically fall to 19 employees or fewer (as the cut-off to apply the new program is 20 workers), and a lot of undocumented casual laborers will find themselves working where previous more legit labor was employed. This still leaves the pesky problems that arise from geography. What do you do about people living in San Francisco but working across the bay? Or vice versa? Of course this all will rely on enforcement of the mandate, and of the proviision of subsidies to those who can’t afford their share of the individual mandate. The smooth application of this is much more uncertain than, say the prospect of lawsuits trying the block the new plan. Which all takes us back to the wider point – connecting health insurance with employment is a dumb idea. But, for now, it’s all a city can do.
This is a national problem, and one that national leadership needs to fix. And in the absence of that? Well the best we can hope for is that the mavericks from San Francisco and Massachusetts make enough noise to keep it in the spotlight until some real grown-ups take charge in Washington.

Share  Posted by Matt Holt at 11:19 PM | Permalink

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