A City's Answer to the Uninsured

San Francisco aims to provide care to 82,000 residents without health insurance. Will other cities follow suit?

Since it launched last summer, San Francisco's groundbreaking initiative to give uninsured city residents a medical home has enrolled nearly 4,000 people and caught the eye of city and state officials around the country. The Healthy San Francisco program seeks to provide healthcare to the estimated 82,000 city residents who are without health insurance. But unlike traditional insurance, enrollees have to obtain medical examinations and other health services by visiting participating clinics and hospitals throughout the city.

Steve Heilig, who was a member of the advisory group that helped design the program and is director of public health and education at the San Francisco Medical Society, says the program has largely been supported by San Francisco's medical and professional communities. "The group that designed the program represented all different sectors, including a number of medical professionals and hospitals, and they were all were basically in universal agreement that this was a good thing to do. The only disagreements were over details about how to actually implement it," he says.

One glaring exception, however, is the Golden Gate Restaurant Association, which filed a lawsuit to block a component of the program that would require employers that have 20 or more employees and don't provide health insurance to those employees to contribute to Healthy San Francisco. The restaurant association says the city ordinance violates a federal law by requiring employers to provide coverage for their workers, at city-specified levels, or pay a fee to support the Healthy San Francisco program.

"The Chamber of Commerce, the restaurant association, and a number of employers were part of this advisory group, and they all said it's a great idea, but they didn't want to pay for it," Heilig says, adding that the program was designed with multiple options built into it. "Employers can offer health insurance themselves, they can give access to this program, or they can contribute to a fund that would give people access to this program."

The popularity of the program has actually sparked concern that the medical community may not be able to keep up with demand. Until November 2007, enrollment was limited to adults with incomes at or below the federal poverty level of $10,210 for a single person and $20,650 for a family of four. After November, enrollment expanded to individuals at all income levels with quarterly fees ranging from $60 to as high as $675 for people with incomes at 500 percent of the poverty level--$51,050 for an individual or $103,250 for a family of four.

Public health officials have acknowledged the main hurdle they've faced since starting the program has been keeping up with demand. "The program is able to leverage the existing infrastructure of the 22 city and community-based health clinics and the resources of San Francisco General [Hospital]. San Francisco is unique in that we have a very active and large public hospital and community clinic network. Half of the estimated $220 million that the program is projected to cost is already in place through that network," says Heilig.