Jack Snook expresses his appreciation for Healthy San Francisco in a panel discussion last night. (Photo: Kamal Menghrajani)

It’s been almost five years since San Francisco launched its innovative, universal health plan–Healthy San Francisco–and last night a panel of public health experts and care providers gathered at the Tenderloin’s Glide Foundation to provide a snapshot of how the program is faring.

Glide has a long history of providing services to the poor and marginalized–and advocating on their behalf. Glide’s Freedom Hall was packed, with a smattering of people who indicated they were participants in Healthy San Francisco. Tangerine Brigham, director of the program, spoke first and described the program’s goals: to provide improved access to care through a network of community clinics and hospitals. Of primary importance is for people to have a relationship with a doctor or clinic so they don’t resort to the emergency room for what are essentially primary care problems.

Healthy San Francisco is not health insurance. Participants pay a quarterly fee–on a sliding scale–for care at the clinics and hospitals that participate in the program, which are in San Francisco only. But people don’t seem to be bothered by the geographic constraints. A 2009 survey by the Kaiser Family Foundation found that 94 percent of participants were at least “somewhat satisfied” with the program and 92 percent would recommend to a friend.

Karen Hill is the clinic manager at Glide Health Services. As a provider, she is also highly satisfied with Healthy San Francisco. “From a clinic manager’s perspective,” she says, “I don’t have to worry about where I need to send someone for specialty care. I know they have a place to go. … We are going to be able to get those specialty tests they need. We have access for blood tests and for medications.”

As part of San Francisco’s health care overhaul, businesses with more than 20 employees are required to provide health insurance to their employees. Before implementation of the plan, employers–especially restaurant owners–had worried that this requirement would cost jobs, since businesses in surrounding cities and counties might not bear the same health insurance costs. William Dow, Professor of Health Economics at UC Berkeley, has looked at this issue extensively. “Were there fewer jobs in the City after this happened?” he asked, in reference to the implementation of Healthy San Francisco. “The answer is no.” You can read his full analysis here.

The discussion was peppered with comments and questions from the audience. Many spoke in favor of Healthy SF, including Jack Snook. “I think Healthy San Francisco is the best thing that ever happened to me other than being a teacher for 20 years,” he said. “I’m able to easily attain care through Healthy SF. … It’s been a big blessing in my life.”

Looking ahead to the rollout of federal health care reform in 2014, panelists agreed that San Francisco’s near-universal health coverage makes the upcoming change easier. “We will be in a very unique position as a provider community in 2014,” said Tangerine Brigham, “because we will be far better prepared with our residents in Healthy San Francisco to transition either from Medicaid or into another program.”

The panel unfortunately ended before any discussion of cost of the program could be addressed. The San Francisco Public Press–sponsor of last night’s event–featured an in-depth special report last November. The entire edition is worth a read, but one ominous parting note:

The employer contribution raised relatively modest revenues. Of Healthy San Francisco’s total $177 million budget in the last fiscal year, businesses covered just $12.9 million, or about 7 percent. When city officials created the program they envisioned businesses covering $30 million to $40 million, or at least 15 percent of the cost.

The city’s General Fund picked up nearly eight times that amount — $99.7 million. The contributions of individuals opting to buy Healthy San Francisco for themselves contribute just $5.9 million or a bit more than 3 percent of total costs.

(Flickr:a.drian)

Four years ago, the City of San Francisco launched an ambitious attempt at health care coverage for all. Today, the San Francisco Public Press devotes its winter edition to an analysis of how well “Healthy San Francisco” is working. While tens of thousands of previously uninsured people have enrolled, and now have health care access they did not have before, the costs have been daunting.

In the Public Press report Stephen Shortell, Dean of the UC-Berkeley School of Public Health appropriately summarized the problem, “Healthy San Francisco is a model for health care delivery, but not for payment.”

But, in its detailed report, the Public Press gets at the strains on community clinics.

Participating nonprofit community clinics in the network have been shouldering part of the financial burden. That may be a problem in an economy where health care costs are rising twice as fast as inflation. Some clinics say they are tapped out, and the $114 per-patient per-year reimbursement they get from Healthy San Francisco doesn’t come anywhere close to covering costs.

“The program is very, very important,” said Karen Hill, administrative director of Glide Health Services, a large, busy nonprofit community health clinic in the Tenderloin whose base of 3,000 patients includes 1,500 Healthy San Francisco members. “But I think we should recognize that it does not pay for the care of the population.”

At last count, Healthy San Francisco covers 54,348 patients, about two-thirds of the estimated 82,000 San Francisco adults who lack insurance, according to a September report from Mathematica Policy Research of Princeton, New Jersey. (Estimates range widely from 64,000 to 90,000 uninsured adults aged 18 to 64.)

In a survey of patient satisfaction, 94 percent said they were satisfied with the medical care they received through the program.

But clinic directors say that while the program has been great for patients, the clinics themselves struggle to deliver care to ever-growing numbers of people. Some clinics have seen their patient base grow by a third since 2007.

Healthy San Francisco has laudable goals, said Ricardo Alvarez, medical director of the Mission Neighborhood Health Center, and “has expanded care to a vulnerable underserved population.”

But for clinics to make it work, Alvarez said, “it is challenging financially.”

Several clinics, such as Lyon-Martin Health Services in Hayes Valley, have stopped taking more Healthy San Francisco patients. The center was already under financial stress this year, and announced earlier this year it had been on the brink of bankruptcy.

 

Public Press details the different funding streams and explains the budgetary shortfalls. But it also points to potential savings.

Shifting to the patient-centered model has also dramatically cut the use of city emergency rooms for routine care by the program’s participants. Proponents say that in the long run emergency room “diversion” — catching illness before it becomes acute — has the potential to save the city millions of dollars a year because emergency care is inevitably more expensive.

Public Press doesn’t address how great those potential savings could be, but it seems unlikely that ER diversions would save enough to offset the cost of covering tens of thousands of people in community clinics.

The Public Press also reports on Healthy SF’s implementation of electronic medical records and the troubling decline of employers providing health insurance and instead are opting for a less expensive way to meet the requirements of the law.