The New York Times
Friday 14 September 2007
San Francisco - Since contracting polio at age 2, Yan Ling Ho has lived with pain for most of her 52 years. After she immigrated here from Hong Kong last year, the soreness in her back and joints proved too debilitating for her to work.
That also meant she did not have health insurance. Not wanting to burden her daughter, who was already paying her living expenses, Ms. Ho delayed doctors' visits and battled her misery with over-the-counter medications.
"Sometimes the pain was so bad, I would just cry," she said. "I didn't know what else to do."
Last month, unable to bear her discomfort any longer, Ms. Ho went to North East Medical Services, a nonprofit community clinic on the edge of Chinatown, and discovered to her delight that she qualified for a new program that offers free or subsidized health care to all 82,000 San Francisco adults without insurance.
The initiative, known as Healthy San Francisco, is the first effort by a locality to guarantee care to all of its uninsured, and it represents the latest attempt by state and local governments to patch a inadequate federal system.
It is financed mostly by the city, which is gambling that it can provide universal and sensibly managed care to the uninsured for about the amount being spent on their treatment now, often in emergency rooms.
After a two-month trial at two clinics in Chinatown, the program is scheduled to expand citywide to 20 more locations on Sept. 17.
Whether such a program might be replicated elsewhere is difficult to assess. In addition to its unique political culture, San Francisco, with a population of about 750,000, has the advantages of compact geography, a unified city-county government, an extensive network of public and community clinics and a relatively small number of uninsured adults. Virtually all the city's children are covered by private insurance or government plans.
At the bustling North East Medical Services clinic, where the staff and the signs are multilingual, doctors and nurses are trying to build trust with patients who may have last sought treatment from an herbalist. Families crowd the elevators, as teenagers help parents and grandparents navigate the system. Patients like Ms. Ho say they hope their access to the clinic's services will bring them independence, and a chance to work.
Healthy San Francisco provides uninsured San Franciscans with access to 14 city health clinics and 8 affiliated community clinics, with an emphasis on prevention and managing chronic disease. It is, however, not the same as insurance because it does not cover residents once they leave the city.
After a phased start-up, the city plans to bring private medical networks into the program next year, expanding the choice of doctors. Until November, enrollment will be limited to those living below the federal poverty line ($10,210 for a single person; $20,650 for a family of four). Then it will open to any resident who has been uninsured for at least 90 days, regardless of income or immigration status.
Only then will city officials learn whether the program appeals to middle-class workers, who make up a growing share of the uninsured. And only then can they test whether San Francisco has the medical infrastructure to handle the desired increase in demand, and to do so without raising taxes.
So far, enrollment has exceeded expectations. The city projected that 600 to 1,000 people would sign up by the end of August. More than 1,300 did, even though officials have done little marketing. They hope to enroll about 45,000 people - more than half the city's uninsured - in the first year. Some clinics are adding night hours and small numbers of workers.
"We really didn't know what the interest level would be, so we're very pleased," said Mayor Gavin Newsom. "At the same time, we don't want overexuberance yet because we don't want to fall of our own weight."
At the two pilot clinics, efforts are first made to qualify patients for Medicaid or other state and federal insurance programs. Those left over receive a Healthy San Francisco card that makes them eligible for primary care, dental exams, mental health and substance abuse services, hospitalization, radiology and prescription drugs.
Because the coverage is not portable, officials believe that people with private insurance will have little incentive to drop their policies to take advantage of the city's cut-rate services.
Like Ms. Ho, many of those enrolling were already using the city's health clinics - or the emergency room at San Francisco General Hospital - in times of acute need, like an asthma attack or stroke. About 57,000 of the 82,000 uninsured San Franciscans have used the city's health system at some point.
But the new program hopes to persuade them to become regulars who regard their neighborhood clinic as a medical home. Once enrolled, patients are assigned a physician and encouraged to get blood pressure checks, mammograms and other screenings.
"We had a system that was not a system, and was based on episodic visits for chronic and acute care," said Dr. Mitchell H. Katz, the city health director. "The idea that you should come get a cholesterol test, that didn't happen."
Nor was it uncommon for patients to ignore doctors' orders because of cost. Before the program started in July, a clinic doctor had ordered X-rays and blood tests for Ms. Ho, but she never got them.
"Now I feel more comfortable coming in to get services and following the doctor's instructions," she said, speaking through an interpreter. She added that she recently had the recommended tests and is waiting for results.
The program was born of the city's impatience with federal and state inaction, Dr. Katz said. In 1998, voters overwhelmingly endorsed universal access to health care in a citywide referendum. Over the years, city officials explored ways to provide universal insurance but, like other governments, could not figure out how to pay for it.
"What we did next was profound and simple," said Mr. Newsom, who shepherded the program with Supervisor Tom Ammiano. "We asked a different question. We asked: How do we provide universal health care to all uninsured San Franciscans? And that one modest distinction allowed us to answer the question we hadn't been able to answer for a decade."
Tangerine M. Brigham, the program's director, projects that it will cost $200 million the first year, and Mr. Newsom expects to finance it without a tax increase. The city already spends about that much on care for the uninsured, and that money will essentially be redirected to Healthy San Francisco.
The program was also selected by the state to receive a three-year federal grant worth $24 million a year for expanding access to care. And because enrollees are still uninsured, they remain eligible for state and federal benefits, like discounts on AIDS drugs.
Patients are asked to contribute nominal amounts through membership fees and co-payments that vary by income.
Those from families with incomes below the federal poverty line pay nothing. Those who earn more pay quarterly fees that range from $60 to $675, which is the rate for those with incomes above 500 percent of the poverty level ($51,050 for a single; $103,250 for a family of four). That is where the subsidy ends. The co-payments range from $10 to $20 for a clinic visit and from $200 to $350 for an inpatient stay.
A final financing mechanism has placed the program in legal jeopardy. To make sure the new safety net does not encourage businesses to drop their private insurance, the city in January will begin requiring employers with more than 20 workers to contribute a set amount to health care. The Healthy San Francisco program is one of several possible destinations for that money, with others being private insurance or health savings accounts.
Late last year, the Golden Gate Restaurant Association challenged that provision in federal court, arguing that it violates a law governing employer health benefits. A judge has scheduled a hearing for early November.
Mr. Newsom, a restaurateur and former member of the association, said the program would work only if accompanied by an employer mandate. But he said the city would have contingencies if it lost in court. "It may set us back," he said, "but it's not going to end this program."
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