Universal Coverge from the Bottom-Up

What we did was ask a profound and simple question? We asked: How do you provide universal coverage to all uninsured San Fransicans?

Gavin Newson, San Francisco Mayor

Rethinking will not give us the answers, but it might force us to ask the right questions…Management is doing things right, leadership is doing the right things.

Peter F. Drucker (1909-2005), Father of Modern Management Theory

When reading a blog like this on health reform, you might legitimately ask, “ All right, h e keeps telling us how complex things are. But does he have any answers?”
It is easy, you see, to criticize but hard to offer constructive solutions. One way to respond is to reframe the question. A logical answer may ensue.

Our Top-Down Paradigm

When speaking of universal health care, we invariably think of universal care from the top-down from the federal government. That’s our paradigm – our mental mindset. We ask our federal government for bailouts. We ask,”Big Brother, can you spare a dime – or a billion or two , here or there?

Moaning and Groaning

We moan and grown about the 15% of uninsured Americans; we mouth sound bites “We’re the only developed industrial society without universal care.” We negatively compare our health statistics on longevity, infant mortality, and health costs to other countries. We talk incessantly of lack of a single payer system as a “moral blight” on America.

But What about River City?

We rarely, if ever, di we stop to ask: “What can we do right here in River City?” Well, back in 2006, San Francisco officials asked the question,"What can we do in the San Francisco Bay ares? They realized they were already spending $150 million or so on the uninsured. Could they do things differently?

Rethinking San Francisco’s Situation

They rethought their situation. In 2006, San Francisco was a city of 750,000 with 82,000 uninsured – nearly 11% of the population, but less that the then national average of 15%. San Francisco had certain advantages – a liberal political climate, a compact geography, a unified city-country government, 22 community and private medical clinics.

Why Not? They Asked

Why not, they asked, get the private sector, the public sector, and the University of California in San Francisco to agreed to cover the 82, 000 uninsured - most of whom were employed but others unemployed,self- employed, homeless, or with AIDs or other pre-existing illnesses - with a reasonable and compassionate fee-schedule to enroll – nothing for those under the federal poverty line, $3 to $20 for those above that, with an average of $35 for most?

Why not offer laboratory tests, X-rays, and hospitalization? Why not publicize it by called calling it Healthy San Francisco, or San Francisco Health Access Plan?

The Answer

The answer to these simple questions was: San Francisco could afford to carry out their plan for $203 million without a huge budget deficit. And they did. After pilot projects to work out the wrinkles, the plan is now in full swing, and San Francisco is happy.

Fulfilling a Moral Obligation

The City on the Bay is fulfilling its moral obligation. It is covering the uninsured at a price it can afford. Its citizens no longer need to worry about access, and the health care establishment - public and private, doctors and hospitals and clinics – by and large feel they are doing the right thing on their own terms, rather than the terms of the federal government.

As it turns out, there may be more than one way to skin the universal coverage cat. And maybe, just maybe, the idea of bottom-up universal coverage might spread to other metropolitan areas.

Closing argument

Does “universal coverage” have to come from D.C.?
D.C. stands for “Darkness and Confusion,” but it sounds free.
Maybe, just maybe, it can come directly from Bagdad on the Bay,
Well local activists innovated and have had their day.
Now universal coverage is everybody’s cup of tea.