Patients happy with San Francisco plan for uninsured

The vast majority of enrollees in San Francisco's health program for the uninsured give it very high marks, but a minority report more difficulty accessing care or higher bills compared with the city's previous safety net system.

Healthy San Francisco, launched in July 2007, provides health care and medical homes to uninsured adults through more than two dozen health centers and three hospitals. Participants pay sliding-scale fees and co-pays for certain care, but those earning less than the federal poverty level pay nothing. The program cannot be used to access care outside the city.

Ninety-four percent of enrollees said they are satisfied with the program overall, according to a Kaiser Family Foundation survey of more than 1,000 people who had been in the program for at least four months as of March 1. More than 45,000 uninsured residents were enrolled by late August. About 82,000 San Francisco residents were uninsured in 2007.

Healthy San Francisco is a revamping of the city's public health network, which provided care to about 50,000 uninsured residents. The program uses the medical homes to encourage better care coordination. "We want people to go to their primary care medical home, establish a relationship, and have a usual source of care so they don't have to rely on an emergency room for their primary care," said Tangerine Brigham, MPP, the program's director and the city's deputy director of health.

The survey results were not entirely positive. Although about half reported easier access to care, 29% said that at least one task -- such as getting specialist appointments or getting medical advice by telephone -- is more difficult. More than a quarter reported delaying or skipping care or medicine.

"The program has some complexities as you reach into a higher level of care," said Edward Chow, MD, San Francisco health commissioner and executive director of the Chinese Community Health Care Assn., a 229-physician practice participating in Healthy San Francisco. For example, administrators are still defining the program's responsibilities for more complex care, such as hand surgery.

Demand has been strong. At least six of the health centers have reached their capacity for enrollees at various times, Brigham said. The kinks reported might be a result of the program's HMO-like structure, said Ronald Labuguen, MD, a family physician who sees patients in San Francisco General Hospital's family care center. Some patients might be accustomed to faster or easier referrals to specialists.

Brigham said the city will not rest on its laurels. "We certainly will be looking into how we can make improvements in the program."

Healthy San Francisco enrollees are similar to the overall patient base typically seen by health centers, said Pat Dennehy, RN, director of Glide Health Services, one of the program's health centers. The center sees about 1,300 of the enrollees, about half of whom are homeless, Dennehy estimated. But the clinic is seeing more working poor or people who lost their jobs and health coverage.

Kenneth Tai, MD, medical director at North East Medical Services, which sees about 11,000 Healthy San Francisco enrollees, said many beneficiaries are probably working for businesses that don't have insurance, or are immigrants or students.

The California Medical Assn. and San Francisco Medical Society have not taken official positions on Healthy San Francisco, but they have been supportive, according to Steve Heilig, MPH, director of public health and education for the city society.

The state and San Francisco societies filed briefs in support of the city in a lawsuit filed by the Golden Gate Restaurant Assn. The lawsuit objects to an employer mandate in the city law creating the program. San Francisco City Attorney Dennis Herrera on Aug. 24 filed papers asking the U.S. Supreme Court to reject the latest employer challenge.

The restaurant association had petitioned the high court to overturn a requirement that employers spend a certain amount on health coverage or else contribute to the program's funding pool. The trade group said the regulation violates a federal law allowing businesses to offer uniform health coverage without dealing with a patchwork of local and state laws.

The 9th U.S. Circuit Court of Appeals twice rejected that argument. City officials maintain that the provision is legal and say overturning it would undermine the effort. Not only have the ranks of the uninsured been slashed, but use of emergency departments has declined 70%, according to the city's brief.

Amy Lynn Sorrel contributed to this story.