San Francisco launching universal health care plan

The city aims to provide basic care to 82,000 uninsured adults, but a restaurant association is fighting the plan's mandatory employer contributions.

By — Posted Aug. 20, 2007

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San Francisco last month began rolling out its plan to provide universal health care to residents through an expansion of its public health safety net and a new employer mandate.

The program, known as Healthy San Francisco, is essentially an upgrade of the city's century-old public health network, which today includes 20 health clinics and one hospital. Fourteen of those clinics and San Francisco General Hospital will provide care to the uninsured. The initiative's planners also anticipate that eight private nonprofit clinics and possibly private health plans and other hospitals will participate.

Keys to the reform effort are coordinating care within the network, using electronic referrals for specialists, giving patients medical homes and focusing on preventive care.

But Healthy San Francisco is not health insurance. Enrollees can only receive care in the program's network, located in the city. "In Oakland you have absolutely no coverage," said Edward A. Chow, MD, senior member of the San Francisco Health Commission, which oversees the city's health department, and past president of the San Francisco Medical Society.

The plan also requires employers in the city to contribute to the health care of employees who work in San Francisco, regardless of where they live. Companies must pay at least $1.17 an hour per employee for their health care starting, at the latest, in April 2008. Businesses with fewer than 20 employees are exempt from the mandate.

The employer contributions are expected to raise $2.1 million between January and June 2008 and significantly more the next year, said Tangerine Brigham, director of Healthy San Francisco.

But that's only if the city fends off a legal challenge to the mandate from the Golden Gate Restaurant Assn., which represents 850 restaurants in the area. The association argues that the federal Employee Retirement Income Security Act prohibits local health care spending mandates. A decision in the case could come as early as this month, said Kevin Westlye, the association's executive director. Brigham said Healthy San Francisco would continue even if the mandate is struck down.

The city already spends at least $115 million annually to care for about 50,000 of its 82,000 uninsured residents through its safety net system. Two-thirds of the uninsured earn less than the poverty level, Brigham said. The expansion is largely funded with a $73 million state/federal Health Care Coverage Initiative grant spread out over three years. Nine other California jurisdictions received the grant, awarded in the spring to support innovative, noninsurance-based proposals to care for the uninsured.

Employers must help out

The program has its roots in San Francisco Mayor Gavin Newsom's Universal Healthcare Council, created in February 2006. Members recommended a plan to cover the city's uninsured adults through the city's clinics and hospital. The city already covers 99% of residents 19 and younger through various city, state and federal programs.

San Francisco Supervisor Tom Ammiano combined the recommendations in his Worker Health Care Security Ordinance, which also mandates employer health care spending. The ordinance passed 11-0 in July 2006.

Starting Jan. 1, 2008, businesses with 50 to 99 employees must spend $1.17 an hour on health care for workers, and those with 100 or more employees must spend $1.76 an hour. Then on April 1, 2008, the $1.17 an hour rate will apply to businesses with 20 to 49 workers. Nonprofit companies with fewer than 50 employees are exempt. Up to 16,000 employees are expected to benefit from the mandate, Brigham said.

Employers can fulfill the ordinance's obligation by providing private health insurance, reimbursing employees for the cost of health care, contributing to a health savings account or helping employees pay for the cost of Healthy San Francisco.

Workers who want to enroll in Healthy San Francisco must live in the city and not be eligible for public health programs such as Medicaid. Those earning less than 500% of the federal poverty level are eligible for sliding scale discounts on program fees. Healthy San Francisco does not cover dental or vision care but does provide mental health and substance abuse services and prescription drugs.

If an employer chooses to contribute to the cost of Healthy San Francisco but not all of its workers live in the city, it can contribute to nonresidents' health care via medical reimbursement accounts.

Better tracking of patients

The city is phasing in Healthy San Francisco over 18 to 24 months, in part, because it's dealing with both new patients and a new system to coordinate care.

Enrollment began at two health clinics -- one city-owned and one private -- on July 1. As of early August, more than 800 people have signed up, Brigham said. The city plans on enrolling more than 4,000 people a month throughout the plan's full network starting Sept. 1.

A new patient referral system and a program to quickly determine eligibility for public health coverage are being tested and refined during the phase in. Nurse practitioners already screen and prioritize patients, but the new system will allow them to refer patients to specialists via a network-wide electronic system.

Wait times have been an issue at city health clinics, Dr. Chow said. While urgent cases are seen more quickly, he's heard of patients waiting several weeks for a routine visit at certain clinics.

The plan calls for hiring an additional 21 physicians and nurses, Brigham said. It also includes renovations for some clinics. Program officials will keep a close eye on capacity, she added.

The San Francisco Medical Society hasn't taken an official stance on the program, but society leadership has participated in advisory and implementation committees, said Steve Heilig, MPH, the society's director of public health and education.

So far, Brigham said, there are no plans to reach out to private physician practices to expand the Healthy San Francisco network. Gordon Fung, MD, immediate past president of the SFMS, said physicians are taking a wait-and-see attitude.

"The program is set up so that physicians will not be overly impacted or negatively impacted," he said.

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A healthier San Francisco

Healthy San Francisco is an effort to provide basic, preventive health care to 82,000 uninsured city residents between the ages of 19 and 64. The plan:

  • Will care for enrollees in 14 of the city's 20 health clinics and one hospital. It is also anticipated that eight private, nonprofit clinics will participate. About 50,000 of the 82,000 uninsured already receive care in the city's system. Applicants can't be eligible for other public health programs.
  • Is not health insurance. It does not provide care for people when they're outside the city.
  • Will charge individuals, based on income, quarterly program access and per-visit fees. For example, those earning less than the poverty level will pay no quarterly fee, while those earning more than 500% of poverty will pay a $675 quarterly fee.
  • Is being phased in over 18 to 24 months. It began with patient enrollment at two health clinics, one public and one private, in early July. The city's 13 other clinics -- and likely seven other private centers -- are expected to begin enrolling patients in early September.

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