San Francisco’s Leg Up on the Affordable Care Act

Health Access is pleased to post the guest blog below from Tangerine M. Brigham, Deputy Director of Health and Director of Healthy San Francisco. We were original and active advocates for the creation of Healthy San Francisco, and of Low Income Health Programs (LIHPs) in other counties. These programs have become not just a critical “bridge to health reform” for those who will get expanded coverage under the ACA in 2014, but could and should be a model for how we can address the needs of the remaining uninsured moving forward.

San Francisco’s Leg Up on the Affordable Care Act
Think the full implementation of the Affordable Care Act in 2014 will take care of the challenges of the uninsured? Think again.

Even after full implementation, the Congressional Budget Office estimates that some 30 million Americans will remain without health insurance. Some of these will be people who, despite the broader reach of health coverage, still will be unable to afford insurance. Others will choose to pay the fine rather than purchase insurance. Others will abstain from coverage for religious reasons. And undocumented residents are not covered by the ACA.

Regardless of the reasons, the fact remains that there will be human beings in need of care and without insurance after January 1, 2014. And, unless there is a better system available, they will do what millions before them have done: become confused by a disjointed public health care system with no clear access point, fear the out-of-pocket costs they might incur, miss out on preventative care, delay treatment, and end up in the emergency room when conditions are most critical and care is most expensive.

Fortunately, there is a better system. Healthy San Francisco (HSF) provides access to affordable, high-quality care for tens of thousands of uninsured adults each year, and has served more than 116,000 San Franciscans since it began in 2007. As the newest case study reports, HSF is not health insurance, but it does provide many of the benefits that make patients more at ease, and more likely to seek preventative care and earlier treatment.

Created and operated by the San Francisco Department of Public Health, HSF is especially notable for three reasons:

• First, it simplifies and streamlines access to health care, coordinating public and private nonprofit providers into a single, understandable system for health care consumers. It even maintains a centralized customer service center to help participants with questions, complaints, access, or billing issues.

• Second, it provides every consumer with a “medical home,” a clinic site that is the first stop for all health care needs and is focused on delivering the highest quality. This makes participants feel more at ease seeking care, and has cut avoidable emergency department visits to less than half of the state’s average for adult Medicaid recipients.

• Third, it is supported by a wide variety of stakeholders. San Francisco City and County cover the bulk of costs. Providers receive partial reimbursements for the care they provide to HSF participants, and cost of services over reimbursement levels are considered a contribution to HSF. Participants pay quarterly participation fees (premiums) and point-of-service fees (co-pays) when they use services, which alleviates the “how much is this going to cost” anxiety. Even employers chip in a portion of health care costs, per San Francisco law, either by offering private insurance, contributing to health savings accounts, or paying into HSF.

HSF isn’t perfect. It is NOT insurance, and therefore does not offer as many services or benefits. It is not available for any medical care administered outside of San Francisco. And enrollment in HSF will show up as a gap in coverage when participants apply for private insurance.

What HSF does provide is a way to help uninsured adults get the health care they need sooner, more easily, and with fewer hassles — and at a cost that’s lower than offering health insurance. The cost of HSF on a per-participant, per-month basis is $255 in 2012, compared to $380 for Medicaid and $402 for private insurance. (Granted, both health insurance products typically offer more services and a broader network than HSF, which will contribute to higher costs.) HSF also helps reduce expenses from avoidable emergency department visits — the go-to access point for many without health insurance in most communities.

When the Affordable Care Act is fully implemented in 2014, San Francisco expects to see a relatively smooth and seamless transition as compared to many other cities. That’s because HSF has already rallied the community around the notion of providing care, helped providers to become more efficient in providing care, and earned the trust of thousands of San Franciscans who will be better informed as they shop for new insurance coverage on the health care exchange. Best of all, those who remain uninsured will be able to rest assured that they still have a solid, caring safety-net for high quality health care.

Check out the full HSF case study and learn more at

By Tangerine M. Brigham
Deputy Director of Health and Director of Healthy San Francisco
San Francisco Department of Public Health

Health Access California promotes quality, affordable health care for all Californians.