Golden Gate to Health Care for All? San Francisco's New Universal-Access ProgramMitchell H. Katz, M.D. Impatient with the lack of progress at federal and state levels in reducing the number of uninsured Americans, many counties across the United States are seeking their own solutions to the health care crisis. Unfortunately, local efforts to achieve universal coverage often encounter substantial obstacles, including the high cost of insurance plans, the loss of federal and state revenues that benefit the uninsured, and limited authority to mandate insurance coverage.
To broaden access while avoiding these problems, the government of the City and County of San Francisco launched Healthy San Francisco (HSF) in April 2007. Building on the success of an earlier effort to provide health insurance for nearly all the city's children, HSF is a novel initiative designed to make comprehensive health care available to San Francisco's 73,000 uninsured residents (13% of adults under the age of 65 years).1
Currently in the form of a phased start-up, HSF is not an insurance program but rather a restructuring of the county's health care safety net. Administered by the San Francisco Department of Health, where I am director of health, HSF's universal-access model features key elements of managed care, such as "medical homes," defined participation and point-of-service fees, and customer service. It provides inpatient and outpatient care, tertiary subspecialty care, prescription coverage, laboratory services, durable medical equipment coverage, and treatment for mental illnesses and substance abuse. (Cosmetic procedures, dental services, fertility treatments, organ transplantation, vision care, and long-term care are excluded.)
All uninsured residents between 18 and 65 years of age are eligible to enroll in HSF regardless of income, employment status, immigration status, or preexisting conditions. During an online application process, clients' eligibility for federal and state programs such as Medicaid is first determined. Those who are eligible can enroll in the appropriate program; those who are not are enrolled in HSF and choose a primary care home from among 14 county and 8 private nonprofit clinics. (As enrollment grows, we hope to broaden the network of providers.) Participants are given an identification card, a handbook explaining how to obtain services, a list of standard point-of-service charges, and access to multilingual customer assistance. Participation is free for residents whose incomes fall below the federal poverty level. Others pay quarterly participation and point-of-service fees (see Table 1 and Table 2), with total fees for those at or below 500% of the federal poverty level amounting to less than 5% of family income to ensure affordability.2
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Source InformationDr. Katz is the director of health, San Francisco Department of Public Health, San Francisco.
http://content.nejm.org/cgi/content/full/358/4/327?query=TOCThe New England Journal of Medicine is owned, published, and copyrighted © 2008 Massachusetts Medical Society. All rights reserved.
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