How San Francisco Does Universal Health Coverage

SAN FRANCISCO (March 23) -- Legislation to overhaul America's health care system has finally won approval in Washington, but in San Francisco, a system of universal health care is already in place.

The three-year-old program, known as Healthy San Francisco, has a public option and does not exclude any patient with a prior medical condition. The only catch is that coverage is available only within the 49 square miles that make up San Francisco.

"It's not perfect. It's not portable. It's not insurance. But it's health care," San Francisco Mayor Gavin Newsom likes to say.

States like Hawaii and Massachusetts provide a public health care option, but San Francisco is one of the few cities or counties to offer universal health care for the poor and uninsured.

The program has enrolled 51,000 uninsured adults in San Francisco. The poorest residents pay no monthly fee. Others pay up to $150 a month, depending on their income. Patients can choose to receive care at one of three dozen public and private clinics and hospitals.

Healthy San Francisco Director Tangerine Brigham notes that the program offers several features included in the federal legislation:

• Medical homes for uninsured patients.
• A choice of providers.
• A focus on preventive care.

Healthy San Francisco costs the city less than $300 a month per patient, Brigham said.

"We have done those things and we haven't disrupted the health insurance market," she said. "More importantly, people seem to be satisfied and, my god, it's run by the government -- a public option."

A survey of patients by the Kaiser Family Foundation in August found that 94 percent were satisfied with the program. A study by the city found that members' emergency room visits dropped 27 percent in the second year, suggesting that the program will help cut costs.

Businesses with 20 employees or more that do not provide health care for their employees must contribute $1.31 an hour for each worker. Businesses with more than 100 employees must pay $1.96 an hour.

About 1,000 businesses have chosen to pay into the program rather than provide health insurance or reimbursement. About $14 million of the program's $126 million budget comes from their payments.

Restaurant Owners File Suit

The Golden Gate Restaurant Association filed suit in 2006 seeking to block the required employer contribution and won in district court. The decision was overturned by the U.S. 9th Circuit Court of Appeals, and the restaurant owners appealed to the U.S. Supreme Court. The high court is considering whether to accept the case.

But even the restaurant association praises the program's success in providing medical care for the uninsured.

"What Healthy San Francisco does is improve the health care safety net, and no one can be opposed to that," said Kevin Westlye, the association's executive director. "It's the employer mandate we object to."

When the program began, the North East Medical Services clinic on the edge of Chinatown was flooded with thousands of new patients. Many had serious health problems that had long been neglected, including debilitating strokes and undetected cancer, because they could not afford to see a doctor, said Dr. Kenneth Tai, the clinic's medical director.

A nonprofit community clinic with five locations, North East Medical Services was one of the first two providers to accept Healthy San Francisco patients. Today, about 11,000 of the clinic's 40,000 patients are enrolled in the program.

Initially, the clinic had so many new patients seeking frequent doctor appointments that it imposed co-payments, $5 for the poorest patients and $10 for those with higher income.

"Once patients get their universal access program, the demand is very great," Tai said. "They all want to come and see a doctor."

The clinic receives a flat fee from the city for each patient and provides all primary care services, preventive care visits, urgent care, medications and lab work. Patients with serious problems are referred to a hospital.

"Fiscally speaking, it is at best break even," Tai said. "The reimbursement is definitely not high. We try to provide the best quality care without breaking the bank."

With Healthy San Francisco, Tai sees an emphasis on prevention, which he hopes will lead to a healthier community and lower medical costs.

"It's really going from a paradigm of taking care of the sick to a model that tries to prevent people from getting sick," he said. "That's where we are heading with Healthy San Francisco and where we are heading as a nation. We are very excited about that."

Machinist Never Thought He'd Need It

Aurelio Duran, now 64, never thought he would need a program like Healthy San Francisco. He worked as a machinist for an Oakland company that made artificial hearts and planned to retire at 66.

But the company went broke in 2006, and he lost his job. He kept his health insurance, but his doctor had a dispute with the insurance company and stopped accepting his coverage. When Duran suffered an excruciating bout of kidney stones, his doctor didn't want to see him.

As Duran struggled to get the care he needed, he learned of Healthy San Francisco and its goal of ensuring that every resident receive adequate health care. He was delighted to discover he was eligible -- and that it was free. He made San Francisco General Hospital his medical home and was soon on the road to recovery.

"I feel great," said Duran, who came to the U.S. from Ecuador in 1969. "My health has improved greatly. The hospital is full of good doctors."

The biggest disadvantage for Duran is that the program is limited to San Francisco; he has no medical coverage when he leaves the city. If he has an emergency and ends up in the hospital elsewhere, he is responsible for the entire bill. He thinks twice about crossing the Bay Bridge, even for the afternoon.

"When I have something important to do, I have to take my chances," he said. "Otherwise I would feel like a prisoner in my home."

Chef Says We Should Eat Better Instead

Leading the fight against Healthy San Francisco is Daniel Scherotter, the chef and owner of Palio D'Asti restaurant. For him, the issue is financial, not medical: He doesn't believe businesses, particularly restaurants, should have to pay for universal health care.

"San Francisco loves its restaurants, but it doesn't treat us very well," said Scherotter, past president of the Golden Gate Restaurant Association, which brought the lawsuit challenging the Healthy San Francisco law.

Creating the program is one of several city actions that have made it hard for small businesses to survive, he said. San Francisco's $9.79 hourly minimum wage and its required nine days of employee sick leave are among the highest in the nation, he noted, and already place a burden on labor-intensive businesses such as restaurants.

Many restaurants have added a Healthy San Francisco surcharge to their menus as a way of covering their costs and mounting a small public protest.

Scherotter would like to see the city -- and the nation -- take a different approach to health care: spend more on better quality food and less on health insurance.

Europeans who eat a Mediterranean diet are healthier than the average American, he noted, not because their doctors are better but because their food is healthier.

"People spend very little money to eat crap and then have to pay for health insurance," he said. "It would make more sense for employers to give lunch insurance to their employees."

Construction Owner Favors Program

On the other side of the lawsuit is Nibbi Brothers, a 60-year-old San Francisco construction company that pays union wages and provides full benefits for its employees. It filed an amicus brief with the Supreme Court urging the justices to uphold the Healthy San Francisco law.

Company president Bob Nibbi said his firm pays more for employees' health care than required under the law, and he thinks his competitors -- especially contractors who cut costs by hiring non-union workers -- should contribute to their employees' medical care.

Without the San Francisco law, Nibbi said, employers who chose not to provide health insurance would force taxpayers to pick up a greater share of their medical costs.

"Basically they are not paying the full freight for the necessary health care that employees and their families are going to need," he said. "They are taking advantage of the public system, the public resources that are out there and supported by the taxes that we pay."