The program is a pioneering effort but will budget cuts damage it?
San Francisco is getting national attention for its attempt at universal health care. President Obama even applauded the city's efforts in a speech: "Instead of just talking about health care, [San Francisco has been] ensuring that those in need receive it."
But Healthy San Francisco a pioneering effort to do at the municipal level what the federal and state governments won't is running into some troubling problems, made worse by Mayor Gavin Newsom's budget cuts.
The program was initiated by Tom Ammiano, now a state assemblymember, with backing from organized labor. Ammiano's goal was to provide easy access to affordable health care for all of S.F.'s 60,000 uninsured. A local version of a single-payer program, he argued, could provide accessible primary and preventative care, alleviating the need for indigent patients to use the overcrowded and expensive San Francisco General Hospital emergency room as their primary medical provider.
Healthy San Francisco was launched on July 2, 2007, at two Chinatown clinics. It has grown dramatically, and now provides services to more than 34,000 residents at 27 clinics.
Although Newsom sat on the sidelines while Ammiano pushed the legislation, the mayor has now unashamedly claimed the program as his own to promote his gubernatorial campaign. On his Web site he boldly declares that "he's created the only universal health care program in the country" with no mention of Ammiano.
The $200 million-<\d>a-<\d>year program is partially funded by an employer-mandate requiring businesses with more than 20 employees either to provide health insurance or pay a fee to the city. The fees are broken down according to the size of the business; as of January 2009, employers pay between $1.23<\d>$1.85 for every hour an employee works.
Like any traditional health insurance program, Healthy SF has annual fees and point-of-service charges paid by participants. The remainder of the program is funded through state grants.
Opposition to HSF surfaced immediately. The Golden Gate Restaurant Association sued the city even before the program started, alleging that the employer-spending mandate is a violation of federal law.
Kevin Westlye, the association's executive director, claims his beef is not with the health care system, just with the employer mandate. He suggested that the city raise its sales tax to pay for the program or that the financial burden should fall on the backs of the billionaires that run privatized health care and pharmaceutical companies.
But the city has only a limited ability to raise taxes, and any tax hike would require voter approval. The employer mandates and fees were much more politically feasible.
Deputy City Attorney Vince Chhabria, who is representing the city on the case, argues, "It is difficult to imagine, in these budget times, that San Francisco could provide universal coverage without employer health care spending requirements."
Federal courts sided with the GGRA initially, but the Ninth Circuit Court of Appeals agreed that the employer-spending mandate was legal. The GGRA appealed to the United States Supreme Court; the court will announce Oct. 5 whether it will hear the case.
That's not the only litigation facing HSF. A group of low-income residents are suing the city, saying that the system's annual fees and co-pays are too high. The program's fees are scaled to the federal poverty level, which is currently set at an annual income of $10,830. A single person making between 101 percent and 200 percent of the federal poverty level that is, between about $11,000 and $20,000 a year pays $180 a year for HSF membership. People earning between $40,000 and $50,000 pay $1,350 a year.
There are also co-pays of $10 for medical visits and $5 to $25 for prescriptions again, typical of health insurance plans.
Bay Area Legal Aid and the Western Center on Law and Poverty are representing three San Francisco residents who say those fees violate federal and state mandates, which stipulate that the city must provide free health care to those who can't afford to pay. Healthy San Francisco is only one element of the lawsuit; it also claims that San Francisco General Hospital charges low-income people too much and that the city's medical bills and collection practices aren't fair.
One of the plaintiffs is Robyn Paige, a San Francisco resident with spine, foot, and hip injuries. Paige contends that she can't afford the co-payments on her multiple medications each month and must either go without pain medication or borrow money. Lisa Qare, 21-year-old resident with MS, had to wait three weeks for medication for an eye condition that developed as a result of her condition.
A $10 co-pay may not seem like much, but when a patient needs several doctor visits a month and must pay $5 to $25 each for multiple prescriptions, it adds up. "As a result," Michael Keys, a Bay Area Legal Aid lawyer, told us, "those who can't afford the charges are falling into medical debt or skipping services or medication."
And, not surprisingly, the cash-strapped city is having trouble finding enough staff and facilities to meet all the needs. Nancy Keiler, a Mission District resident and HSF participant, complains that clinic visits are too short, and that "the doctor is too hurried and has too many patients." (That's a common complaint about private health plans, as well.) After waiting three hours, another HSF participant had to leave without her prescription to get back to work on time.
The long lines and waits will only get worse in the face of budget cuts. Pink slips were already handed out to several hundred San Francisco health care workers and 1,000 more may be laid off this fall.
Robert Haaland, who works with the Service Employees International Union Local 1021, told us the staffing cuts will make the situation much worse. Martha Hawthorne, a public-health nurse, said she thinks that there won't be enough providers to provide good care and that many health care workers losing their jobs will have to enroll in HSF themselves, putting even more strain on the system.
Ammiano, the author of the plan, is concerned too. "I'm very worried about it," he said. "It seems to me now that if there's this budget pain, there will be impacts to San Francisco."
Nathan Ballard, the mayor's press secretary, tersely denied that HSF will feel any budget pain. Asked about critics' allegations, he said, "They're wrong. We are going to expand Healthy SF this year."
Earlier this month, insurance giant Kaiser Permanente joined HSF meaning that the health care giant will now participate as a provider in the program. Haaland voiced concern about that move, calling it "privatizing through the back door."
Mitch Katz, the city's public health director, agrees there are flaws to the system, but defends its success. "It is by no means a perfect program," he said, "but we've made a big impact." With national health care costs rising three times faster than wages (some believe that health care costs are rising five times faster than wages) the nation is starting to seriously talk about overhauling the entire system. San Francisco is being considered as a model for national health care reform.
Labor leaders have lauded the basic formula of HSF and pushed for the federal reforms to use it as a model. As San Francisco Labor Council executive director Tim Paulson said in a prepared statement, "In San Francisco we demonstrated that legislation providing public health access and corporate participation creates a real path to universal health care coverage."
Research assistance by Gabrielle Poccia