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Healthy San Francisco Has Increased Access, Reduced Utilization

Cheryl Clark, for HealthLeaders Media, July 2, 2009

Healthy San Francisco, held up as a model employer "pay or play" strategy, is two years old today—and its supporters view the program as a possible solution to the nation's 47 million uninsured.

The program has added 43,000 of 60,000 targeted San Franciscans to its rolls since it began and has been adding about 1,800 people per month.

The earliest participants in the program appear to have reduced their need for the most expensive kinds of healthcare, such as emergency room care. For example, the number of hospital admissions declined from 28.2 per 1,000 participants to 18.4 and the number of hospital days declined from 103 to 61 per 1,000 participants.

"San Francisco's Health Care Security Ordinance has a number of features that should serve as a model for a national policy," says Ken Jacobs, chairman of the Labor Center at the University of California at Berkeley and co-author of the report, "How to Structure a 'Play-or-Pay' Requirement on Employers: Lessons from California for National Health Reform."

But it is not yet clear about the financial portion of the program, and there are two other questions too:

  • Can the program's timely access to care and prevention improve patient outcomes over the long term?
  • Can members avoid enough expensive care to produce a net savings?

Also unclear is how much support will continue to come from employers, especially those dependent on tourism, if the economy continues to slide. Some businesses fear that scheduled 2010 increases in the amount they will have to pay for each employee hour will provoke some companies to move out of town.

Jacobs, who has studied the city's program, says so far the program is operating well. "Employers have adapted to the SF ordinance relatively easily," he says. "The earliest evidence is that employers are by and large keeping the coverage they have for those workers who were already covered on the job, and paying into the city for those jobs that did not previously provide coverage."

Healthy San Francisco, a program run by the city, provides primary, mental health, and acute care as well as substance abuse treatment for adults under age 65 who have been uninsured for the most recent 90 days, regardless of immigration status. It does not pay for dental or vision care and it is not an insurance program. And all care is provided through "medical homes" in a network of 30 community clinics throughout the city plus Kaiser Permanente as of July 1.

In a nutshell, here's how the program works:

Employers with at least 20 employees must either "pay" the city based on the number of hours their employees work, or "play," which means finance employee health plan coverage at a similar value for their employees. If the employer chooses to pay, but employees do not qualify for Healthy San Francisco, the funds are deposited into a "Medical Reimbursement Account" that the employee can use for out-of-pocket health are expenses.

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