Those without medical insurance are often forced to navigate fragmented health-care delivery systems and are less likely to receive primary care, more likely to rely on costly episodic or emergency care, and have higher mortality. This was no different in the City and County of San Francisco, where there are an estimated 64,000 uninsured adult residents.
San Francisco has been working for years to improve the health-care delivery system for uninsured residents. In 1998, San Francisco voters approved a ballot measure that encouraged the expansion of health care coverage to uninsured residents. Soon thereafter, San Francisco launched several more initiatives: health insurance for In-Home Support Services workers (1999), a requirement that all city and county contractors provide health insurance to their employees (2001), and health insurance for children ineligible for Medicaid or S-CHIP (2002). However, limited progress was made on improving health care for uninsured adults, which comprise the majority of San Francisco’s uninsured.
In February 2006, the City created the Universal Healthcare Access Council, charged with developing a proposal to provide health care to all uninsured adult residents. The Council included representation from health care providers, business, labor, advocacy organizations, philanthropy, research, consumer communities, and other disciplines. The Council recommended development of a new health care access program called Healthy San Francisco (HSF) to be administered by the Department of Public Health.
HSF debuted in July 2007. It provides comprehensive, affordable health care services including primary, specialty, diagnostic, pharmacy, behavioral health, and emergency and hospital care. HSF ensures that all participants choose a primary care medical home; creates one countywide eligibility and enrollment system; provides clear information on eligibility, services, and costs; and employs centralized customer service. HSF does not rely on a health insurance model, which potentially could be financially unsustainable for local governments. Rather, it organizes existing public and private health care providers into a single, more coordinated system of care to connect uninsured adults to a comprehensive array of health care services.
In four short years, HSF was serving 85 percent of uninsured adult residents. The program has had high levels of enrollment, primary care utilization, and satisfaction; and it has helped decrease emergency department visits.
San Francisco has spoken to many communities contemplating similar programs. In 2008, aspects of the program were replicated by Howard County, Maryland, when it launched its Healthy Howard Access Plan. HSF stands to become an effective bridge for moving uninsured residents from this program and into a health insurance option when they become available in 2014 as part of the federal Affordable Care Act.