San Francisco health care approach hailed as a model

Some caution applicability is too limited

SAN FRANCISCO PLAN Mayor Gavin Newsom said the program provides health care 'regardless of your ability to pay, [or] preexisting condition.' SAN FRANCISCO PLAN
Mayor Gavin Newsom said the program provides health care "regardless of your ability to pay, [or] preexisting condition."
By Maria L. La Ganga
Los Angeles Times / October 5, 2009

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SAN FRANCISCO - For two years, three-quarters of San Francisco’s uninsured adults have enrolled in a public program that guarantees access to medical services, and the effort is being touted as a national model during the rancorous health care insurance debate.

More than 46,000 adults have enrolled in Healthy San Francisco since it was launched; this first-in-the-nation, city-run universal health care effort has received high marks in recent independent studies.

The program is funded in part by an employer mandate, a controversial component of the plans under discussion in Washington. One analysis has concluded that this mandate on employers with 20 or more workers has not driven businesses away. Patient satisfaction is high, according to another recent survey.

But although many observers laud the program, which Mayor Gavin Newsom described as “a public option . . . a strategy to provide health care regardless of your ability to pay, regardless of your preexisting condition,’’ even some supportive critics warn against inflating its success.

“It is a stretch to suggest that this is a model for a full-fledged insurance plan acceptable to broad sections of the population that competes head-to-head with private insurance companies,’’ said Dr. Mark Smith, president of the California HealthCare Foundation and an adviser to the San Francisco effort.

Healthy San Francisco is not insurance, is not portable, and is worthless outside of the 49 square miles that constitute the self-proclaimed “city that knows how.’’

But here’s what it does do: Any uninsured adult who lives in San Francisco and earns as much as 500 percent of the federal poverty level annually is eligible. That’s $54,150 for individuals and $110,250 for a family of four. (Children are covered under a separate city-run program.)

Patients must pay a quarterly participation fee based on their annual income, along with certain copayments for services. But care is free for those earning 100 percent of the federal poverty level or below, about 70 percent of all participants.

Patients must pick a medical home out of a network of more than 30 public and private clinics, physician groups, and hospitals within the city limits. The idea is that patients get consistent care and the system avoids duplicating services. Although about half of the network is government-run, Kaiser Permanente just joined and plans to accept as many as 3,000 patients.

Patients receive preventive services, such as mammograms and colonoscopies, care when they are sick or injured, and ongoing treatment for chronic conditions. Prescriptions are covered.

So are hospital stays, which cost participants no more than $200 a day at San Francisco General Hospital.

But if you have a heart attack in Phoenix or go to a provider outside of the limited network, you’re on your own. In addition, dental and vision care are not covered. As the Healthy San Francisco handbook notes, “If you have health insurance, do not drop it.’’

But the program is a lifeline for people like Cayetano Castaneda, 53, who washes dishes at a restaurant in Union Square. Castaneda cannot afford the insurance his employer offers.

Before enrolling in Healthy San Francisco, he stayed away from doctors’ offices, even though he has high cholesterol and suffers headaches and fevers. “I was afraid I would not be able to pay the high bills in the hospital,’’ he said. “I never got care. I waited and waited.’’

Today, he pays $60 every quarter to participate in the program. The Castro-Mission Health Center is his medical home.

Some critics describe Healthy San Francisco as a repackaging of the city’s existing clinic system.

Even before the program began in 2007, Castaneda could have gone to the same clinic, operated by the city’s Department of Public Health, and paid for care on a sliding scale. But city officials say he would not have been able to see a private doctor or be admitted to a private hospital.

Since 2008, private employers here with 20 or more on the payroll have been required to spend a minimum amount on health care coverage for their workers. They can fulfill that obligation by offering insurance, selecting Healthy San Francisco, or paying into a medical reimbursement or health savings account.

“Healthy San Francisco is a really good idea and a good program, a reorganization of the public clinic system giving each resident a medical home,’’ said Kevin Westlye, executive director of the Golden Gate Restaurant Association.

But, he said, “we vehemently disagree’’ with the employer mandate.

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