'Healthy San Francisco': A Different — Better? — Model For Health Reform

Let me tear off my provincial Massachusetts blinders for a moment to say: We're far from the only national laboratory for health reform. And something deeply interesting is going on in that fair city on the left-coast Bay, San Francisco.

So interesting, in fact, that the program, "Healthy San Francisco," is a finalist for a major award from Harvard Kennedy School, the Innovations in American Government Award given out by the Ash Center for Democratic Governance and Innovation. (Winner to be announced early next year.) The 16-minute presentation above to the award judges provides a succinct overview, but here's my one-liner: Unlike Massachusetts, San Francisco didn't try to get everybody insured; it just aims to provide health care to the uninsured people who need it — not just in emergencies, but long-term, primary and specialist care.

I spoke with Berkeley health economist Richard M. Scheffler, who evaluated "Healthy San Francisco" for the innovation awards, about how the program works, and it certainly has its limits — including the city limits: It doesn't extend beyond them. But what struck me is that, beginning in 2007, the program aimed to address health care delivery issues that we in Massachusetts are only getting to in a sweeping way now, such as the question of whether everyone should have to have a primary-care "medical  home."

It also struck me that, though employers and taxpayers foot the bill, Healthy San Francisco addresses the problem of the uninsured by focusing mainly on them, and arguably affects the broad population less than in our health-insurance-for-all state. Readers, what do you think? Would something like Healthy San Francisco work elsewhere, beyond the bounds of that famously liberal city? Would you want it to?

[module align="right" width="half" type="pull-quote"]'The mandate is on the employer, not the individual as it would be in Massachusetts.'[/module]

My chat with Richard Scheffler, lightly edited:

So what's so cool about 'Healthy San Francisco" that it merited being an award finalist? It strikes me as such a dramatically different model from Massachusetts, much more narrowly targeted...?

What's cool about it is that, as you mention in your question, it's a very different approach than Massachusetts — or even the Obama plan. The Massachusetts model is fundamentally based on trying to help people obtain health insurance. But it does nothing about the access problem: the plight of safety net hospitals, lack of primary care doctors, overuse of emergency rooms, uncoordinated care. So San Francisco, to compare it to an insurance approach, it’s what you’d call an 'access approach,' It's actually to provide access to health care.

It does have limits: You have to be a resident of San Francisco; you have to have an address and show you live in the city, and the plan covers you only when you're in San Francisco. So if you have to take the BART train — which is our MBTA train — to visit me in Berkeley, you wouldn't be covered. So it does have its limitations, but it is basically an access program, which is different from an insurance program.


Different — better??

I wouldn't say better. It's a very different approach. Better is a tough term.

Approaches to providing quality and affordable health care for people can vary in different parts of the country, and I think we need a bit of both.

What San Francisco does to provide care is: It has people in one of three options. If you're working, the employer is mandated to spend a certain amount of money on your health care for you. That's a mandate. The mandate is on the employer, not the individual as it would be in Massachusetts.

And so that employer can either buy you insurance, or set up what we call a Flexible Spending Account — put some money in a bank account you can use — or enroll you in the Healthy San Francisco program, which is a publicly run program set up with a series of what we call 'medical homes' — a place where you can get all your care in one particular spot. It’s usually some kind of community clinic.

And then to pay for that, if you're an employer, there is some money added to the wage bill: It's about $2, give or take, for every hour an employee works more than eight hours, that needs to be paid.

That's where that money comes from. And then the state puts in some money on a waiver to help out. And the city puts some of its own public money into it. So there are contributions from different places, that's basically how it's financed.

How you get your care depends on which one of these plans your employer happens to pick for you to satisfy what we call a spending mandate — the amount that the employer has to spend on your health care. It's a flexible model, it's not one-size-fits-all. Some employees encourage their employers to buy insurance for them; some like these spending accounts; and some like the public system of clinics which is set up throughout the city.

This San Francisco program that started back in 2007 seems to address access issues that Massachusetts seems to only be getting to now...

Massachusetts, of course, is a system for an entire state and this is just one city. So it's hard to make those comparisons.

I would have you think about it this way: The number of people we have uninsured in California, which is about 16-17% of the population — that's the entire population of Massachusetts. It's a different scale. The Massachusetts issue is very different from the California issue.

[module align="left" width="half" type="pull-quote"]'No one’s talking about trying to do away with this program. It’s pretty set in the San Francisco culture.'[/module]

But back to Massachusetts, I think the state has done a reasonable job on coverage — it has a high coverage rate, probably in the high 90s, and I think that's a good thing, and they set out to do that. Now they’re finding the problem is the cost of delivering the services. They got people insured and then there was no sort of fix for the delivery system.

In the case of Healthy San Francisco, there are give-or-take 50-60,000 people enrolled in it in total. And the positive thing is that all the parties — the providers, the hospitals, the unions, the employees, the employers — they're all generally happy with the program. Of course, people complain here and there, but generally, no one’s talking about trying to do away with this program. It’s pretty set in the San Francisco culture.

When I talked to the labor representatives and people in the mayor’s office, nobody had any thoughts about, 'We have to get rid of this program.' They all talked about trying to improve it.

What San Francisco did that Massachusetts didn't do is using 'medical homes' and primary care clinics and electronic medical records, and trying to reach out to patients to do prevention and work with them and coordinate their care. That, I think, is a big advantage of what happened in San Francisco and didn't happen in Massachusetts.

But remember, it’s not technically an insurance program, because if you leave the city, you're not covered. It's an access program for residents when you're in the city. It's a very different approach.

What would you say is its biggest problem?

The greatest problem I find is that when you talk to people, they're so used to the influence that Massachusetts has had being a groundbreaking program — and then the follow-up of the Obama plan, which does take a lot of its elements from Massachusetts — that they think Healthy San Francisco is a plan like that. Which it isn’t. So they have really a marketing or labeling problem.

People don’t understand it. And I have found even some of the providers in San Francisco who take care of patients, doctors I've spoken to and hospital administrators, still think people coming in there have insurance, but they don’t.  So the problem is that people don’t understand the program and how it actually works.

And there’s always the issue of who’s going to pay a bigger or smaller share. As I pointed out, the financing comes from different pots of money. Whenever there's money involved, people fight over it. But the good thing about money — that you can't do when you're fighting about principles — is that you can alway divide it up somewhere in the middle.

Why do you think there's not more of a 'Healthy SF' element in the Obama health overhaul?

Actually there is, not in financing but in delivery — medical homes and primary care and prevention. And once the Obama insurance part fully clicks in, I think more communities will start to look at the prevention and community part,  and San Francisco will then be a model of what’s possible, at least in an urban environment.

Is it unique at this point? 

It’s quite unique — that's why it's up for an Innovation Award at the Kennedy school. It’s the only health care innovation among the finalists, so I think that speaks for itself. There's a community program in Maryland called Healthy Howard that's a knock-off, and I think in California now there are a number of counties that are considering doing this as well. But quite frankly, it hasn't spread like wildfire.

Why not? 

I think it just requires leadership at the governmental level. And it requires people to kind of get along. The politics of our day, unfortunately, is not for people to work together, particularly on the political front.

Former SF mayor Gavin Newsom
Former SF mayor Gavin Newsom

Was the culture of San Francisco key? I certainly think of it as a city that is kinder to the homeless, and to the poor in general, than just about anywhere else. 

I don't think it's any surprise to anybody that San Francisco is socially more progressive, and it's definitely more of a liberal city than others in the US. But I don't think it's really about being more liberal. I met with a lot of the people who put the program together, and some credit needs to be given to leadership.

Gavin Newsom was mayor at the time — he's now lieutenant governor, and looking for a higher office after that, no doubt — and he was able to bring all these parties to the table and, I believe in a three or four month period, with a series of meetings, get them to sign on to this. I think it takes some creative leadership from the mayor's office, but it wasn't the mayor alone, to be sure. It was people in leadership positions in San Francisco who understood that it was actually good for everybody for San Francisco to be considered a healthy city.

Editorial post-script: This is all by no means to imply that our Massachusetts reform is chopped liver. The Massachusetts agency that helps people get health insurance, the "Connector," won an Ash Center Innovation Award in 2009.

This program aired on November 30, 2011. The audio for this program is not available.

Headshot of Carey Goldberg

Carey Goldberg Editor, CommonHealth
Carey Goldberg is the editor of WBUR's CommonHealth section.



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