Aspiring to universal access: Healthy San Francisco opens up care

The city's 4-year-old safety net initiative survived a legal challenge to become an urban test bed for improving care coordination under health reform.

By Doug Trapp — Posted May 30, 2011

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Most large American cities have a safety net of community health centers, public health clinics and hospitals, and private practice physicians. But San Francisco has gone a step further -- it has turned its safety net into a health network.

In 2007, the city launched Healthy San Francisco, a unique universal health care access program available to most city residents between 18 and 64 years old. The program provides primary care medical homes plus emergency and specialty care to anyone who earns less than 500% of the federal poverty level, currently $54,450. Participants earning more than the federal poverty level also pay income-adjusted quarterly program fees, which reach a maximum of $450, plus modest co-pays.

Healthy San Francisco is not health insurance, because it doesn't pay for care outside its network, which ends at the city limits. But unlike many other uninsured people, Healthy San Francisco enrollees have continuous care. Each participant chooses a primary care medical home from one of 36 public health clinics, community health centers and physician practices. Most hospital care is handled by San Francisco General Hospital.

"We've had a large safety net, and this is just filling in the gap," said Steve Heilig, MPH, director of public health and education for the San Francisco Medical Society. Heilig also served on a mayoral commission that helped create the program.

Care coordination is the key to Healthy San Francisco. The program's centralized eligibility and enrollment system is available to all medical homes and all participating hospitals. Clinic physicians and hospital emergency departments can find out quickly which facility is a patient's medical home by checking the enrollment system.


Some San Francisco restaurants itemize the city's mandatory health care spending on their receipts. The health care security ordinance -- adopted at the same time as Healthy San Francisco -- requires city businesses to spend at least $1.37 on health care for each employee hour worked in 2011. Photo courtesy of Jonathan Kauffman /

The concept is having some success. Better coordination has reduced hospital admissions and duplicate care. Healthy San Francisco has encouraged the working poor and people who recently lost private health insurance to seek health care, physicians said. The city reports that about two-thirds of the city's uninsured are in the program.

"One of the biggest lessons is how much better we can do on a local level caring for uninsured persons if all of the providers who are caring for the uninsured work together," said Mitch Katz, MD, former director of the San Francisco Dept. of Public Health, which runs the program.

Another lesson learned is that employers can be compelled to help pay for their workers' health costs, Dr. Katz said. Healthy San Francisco was adopted at the same time as a requirement that most businesses spend a minimum level on employee health coverage or contribute to a public health fund that supports the program. A court challenge to the requirement by a local restaurant association ended in June 2010 with the U.S. Supreme Court declining to hear an appeal of a lower court ruling upholding the employer mandate.

Healthy San Francisco offers a look at how the national health system reform law's Medicaid expansion might stress larger cities' health care safety nets. The program has allowed early access to care for many people who will qualify for Medicaid under the health reform law's eligibility expansion starting in 2014.

About 60% of program enrollees are expected to qualify for Medicaid or subsidized private insurance in 2014. City officials expect to continue the program beyond that point, in part because undocumented immigrants will not have access to expanded federal coverage.

Access not always there

The influx of new patients has taxed an already loaded health care safety net in San Francisco. More than 80,000 residents have signed up for Healthy San Francisco since July 2007 -- about 10% of the city's population -- and more than 54,000 were enrolled at the end of April 2011. New enrollees might wait weeks or months for a routine office visit. Specialist care can require even longer waits, although urgent medical problems are prioritized.

Access to medical homes for new patients is based on wait times. At one time in fiscal 2010, as many as eight of the then-32 medical homes were closed to new patients because wait times were longer than 60 days, said the program's fiscal 2010 annual report.

"The only way most clinics have been able to increase capacity is through adding hours," said Hali Hammer, MD, medical director of the San Francisco General Hospital Family Health Center and Urgent Care Center, one of the designated medical home sites. Her center began accepting patients on weekday evenings and Saturday mornings and might expand hours further.

Despite the access challenges, the vast majority of Healthy San Francisco participants are satisfied, according to a 2009 survey by the Kaiser Family Foundation. Physicians say they treat program enrollees the same as other patients, including those in Medicaid or Medicare, although within a more limited network.

Some specialist access, including for mental health care, continues to be problematic. "We could certainly use some more of that," said Albert Yu, MD, MPH, director of the Chinatown Public Health Center, another city facility. Medical home sites have access to San Francisco's behavioral health services system, which contracts with an array of specialists that had to be expanded for the program.

Legacies of delayed care

As will be the case with many of those gaining Medicaid eligibility under the national health reform law, many of Healthy San Francisco's initial enrollees never had a steady source of health care.

"There were amazing stories early on of people who lived in San Francisco their whole lives and never had access to health care," Dr. Hammer said. People showed up with undiagnosed diabetes, high blood pressure or even metastatic cancers. Some women had never had a Pap smear, she said.

Kenneth B. Tai, MD, is medical director of North East Medical Services, the single-largest medical home under Healthy San Francisco. More than 90% of the 15,000-plus program enrollees at his clinic are ethnic Chinese.

One such enrollee is Meiye Lao, 61, a Chinese immigrant. She signed up for the program three years ago, two years after arriving in the U.S. She had never seen a doctor before joining.

She used to visit herbalists, whose treatments helped "a little bit, but not as much as here," she said, speaking through a translator at the clinic in early May. She also has sought treatment for joint pain at the clinic.

Dr. Tai said many of his clinic's patients also rely on herbalists and look for second opinions from other nonphysician sources, including family members. He said he respects alternative medicine but worries because some of the herbalists' drugs have steroids mixed in. These can make people feel better temporarily but can weaken the effects of prescribed medicines and impair body functions.

Ruth Constantino isn't sure how she would have handled the past few stressful years without Healthy San Francisco and the staff at the Family Health Center, one of the city's public clinics. Constantino, 50, went through a divorce, lost her job as a floor manager at the Birkenstock flagship store when it closed, and has had to deal with the deaths of three close friends and family members. She's also caring for her elderly mother.

Constantino signed up about three years ago because she was feeling as if she might have a heart attack or a stroke. "I'd get short of breath, and I was dizzy, and I'd feel some numbness in my neck, so I thought I'd better get it checked out," she said.

Through the program, Constantino received counseling for stress and depression. Just knowing she has a routine source of care helps lower her anxiety. "It really gives me a lot of peace of mind."

Adapting to new patients

Physicians in some Healthy San Francisco medical home sites said they are seeing more young, uninsured but healthy people sign up along with middle-age people starting to develop health problems. Many newer participants once had private insurance but lost their coverage during the latest recession.

This has provided some new opportunities for physicians to reach out to patients. "We're not so used to talking to a 29-year-old who works as a busboy at a restaurant," said Teresa Villela, MD, vice chief of the San Francisco General Hospital Dept. of Family and Community Medicine and a family physician at the Family Health Center. "It's luxurious to have 15 to 20 minutes to talk to a young man about prevention."

The new patient mix has impacted Potrero Hill Health Center at the same time the facility is moving toward a more team-based care model. The center has been hiring more medical assistants, behaviorists and clinical social workers. These changes are not directly due to Healthy San Francisco, but the program's influx of new patients has encouraged clinics to try to use resources more judiciously, said Michael J. Drennan, MD, the clinic's acting director.

"That has helped providers offload some of that work to other staff members," said Dr. Drennan, who also is chief of community primary care service at San Francisco General Hospital Community Health Network. A nutritionist might advise a patient, allowing the physician to focus on more specific medical issues. Nurses focus on more advanced work than just checking vital signs.

The Family Health Center now offers group patient counseling on managing diabetes, emphysema and other conditions, said Ellen Chen, MD, associate director of the Center for Excellence in Primary Care at the University of California, San Francisco.

Long-time patients have had to make adjustments as well. Some physicians said they have had to explain that in a medical home, a patient contacts the same physician for all his or her health care needs.

This didn't always happen under the old city safety net system. But Dr. Hammer said that change is definitely a good thing.

"Now what's different is we're seeing people and we're able to offer them primary care through their adult lives," she said.

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Who uses Healthy San Francisco?

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Click to see data in PDF.

Healthy San Francisco has enrolled most of the city's uninsured residents. Participants are more likely to be female, older and have lower incomes than the city's overall uninsured population in 2008, the year after the program launched.

Healthy San Francisco
enrollees, 2010
Uninsured population
of San Francisco, 2008
Total 53,097 77,021
Men 27,908 45,471
Women 25,189 31,550
18-24 6,949 15,140
25-39 17,082 27,832
40-64 29,066 34,049
Income (as % of the federal poverty level)
0-100% 35,788 21,366
101%-200% 12,234 17,561
201%-300% 4,328 13,774
301% or greater 747 23,534
Asian or Pacific Islander 20,200 27,701
Latino 12,822 18,477
White 10,218 22,848
Black 4,576 5,604
Other (including two or more races) 2,391 5,281

Note: U.S. Census Bureau considers Healthy San Francisco enrollees to be uninsured because the program is not insurance.

Source: "Participation in Healthy San Francisco: Trends in Enrollment and Retention," Mathematica Policy Research, Feb, 28 (link)

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View in PDF

Click to see data in PDF.

Fewer hospitalizations

Hospitalizations among Healthy San Francisco enrollees decreased during the program's first two years. The change in enrollees' rates of emergency department visits varied widely by patient health status.

Acute hospital admissions
Year Total Per 1,000 enrollees
July 2008-June 2009 1,110 30.4
July 2009-March 2010 985 26.0
Emergency department visits
Year Total Per 1,000 enrollees with chronic diseases
July 2008-June 2009 2,043 190.2
July 2009-March 2010 1,647 188.2
Year Total Per 1,000 enrollees without chronic diseases
July 2008-June 2009 3,988 154.6
July 2009-March 2010 4,585 157.4

Source: Annual Report of the San Francisco Health Commission, 2009-10 (link)

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Charity care still plays a major role

Despite having many key parallels with the upcoming Medicaid expansion under the health system reform law, Healthy San Francisco is not a perfect example of a reform test bed. For one thing, the initiative is still largely a charity care program.

The city-owned clinics and the public San Francisco General Hospital receive no payment for the services they provide to program enrollees. Non-city-owned clinics and private physician groups are paid on an annual capitated basis based on the number of enrollees for whom they provide medical homes.

The infrequent billing is a big part of what keeps administrative costs at 5% of the city's overall program spending, a rate closer to that of Medicare than of private insurance. Mitch Katz, MD, former director of the San Francisco Dept. of Public Health, said the city never was trying to pay for the actual cost of providing primary care medical homes. "All of these providers were taking care of the uninsured for free before."

City medical home payments are confidential, but physician leaders at those sites said they are relatively low. "We have to really watch our utilization to make sure we're financially viable," said Kenneth B. Tai, MD, medical director of North East Medical Services, the program's largest medical home.

Healthy San Francisco cost about $160 million in fiscal 2010, of which the city's general fund covered about $140 million. The rest came from federal Medicaid money, enrollee program fees and employers who paid into the public health fund instead of providing health coverage for their workers.

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External links

"Participation in Healthy San Francisco: Trends in Enrollment and Retention," Mathematica Policy Research, Feb. 28 (link)

Annual report of the San Francisco Health Commission, fiscal 2010 (link)

Kaiser Family Foundation survey of Healthy San Francisco participants, February 2009 (link)

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