SAN FRANCISCO — Over the last two years, three-quarters of San Francisco's uninsured adults have enrolled in a public program that guarantees access to medical services, an effort that is being touted as a national model during the rancorous debate over healthcare reform.
More than 46,000 adults have enrolled in Healthy San Francisco since it was launched; this first-in-the-nation, city-run universal healthcare effort has received high marks in recent independent studies.
The program is funded in part by an employer mandate, a controversial component of the plans under discussion in Washington. One analysis has concluded that this mandate on employers with 20 or more workers has not driven businesses away. Patient satisfaction is high, according to another recent survey.
But although many laud the program, which Mayor Gavin Newsom described as "a public option . . . a strategy to provide healthcare regardless of your ability to pay, regardless of your preexisting condition."
But even some supportive critics, including Dr. Mark Smith, president of the California HealthCare Foundation and an advisor to the San Francisco effort, warn against "making more of it than what it is."
"It is a stretch to suggest that this is a model for a full-fledged insurance plan acceptable to broad sections of the population that competes head-to-head with private insurance companies," Smith said.
Healthy San Francisco is not insurance, is not portable and is worthless outside of the 49 square miles that constitute the self-proclaimed "city that knows how."
But here's what it does do: Any uninsured adult who lives in San Francisco and earns up to 500% of the federal poverty level annually is eligible. That's $54,150 for individuals and $110,250 for a family of four. (Children are covered under a separate city-run program.)
Patients must pay a quarterly participation fee based on their annual income, along with certain co-payments for services. But care is free for those earning 100% of the federal poverty level or below -- about 70% of all participants.
Patients must pick a medical home out of a network of more than 30 public and private clinics, physician groups and hospitals within the city limits. The idea is that patients get consistent care and the system avoids duplicating services. Although about half of the network is government-run, Kaiser Permanente just joined and plans to accept up to 3,000 patients.
Patients receive preventive services, such as mammograms and colonoscopies, care when they are sick or injured and ongoing treatment for chronic conditions. Prescriptions are covered. So are hospital stays, which cost participants no more than $200 per day at San Francisco General Hospital.
But if you have a heart attack in Phoenix or go to a provider outside of the limited network, you're on your own. In addition, dental and vision care are not covered. As the Healthy San Francisco handbook warns those who have health insurance, "Do not drop it. Insurance is always the better choice."
But the program is a lifeline for people like Cayetano Castaneda, 53, who washes dishes at a restaurant in Union Square. Castaneda cannot afford the insurance his employer offers and still pay his rent.
Before enrolling in Healthy San Francisco, he stayed away from doctors' offices, even though he has high cholesterol and suffered from headaches and fevers.
"I was afraid I would not be able to pay the high bills in the hospital," he said. "I never got care. I waited and waited."
Today, he pays $60 every quarter to participate in the program. The Castro-Mission Health Center is his medical home. One recent Wednesday, he waited in its busy lobby for blood test results that would tell him if new medication had lowered his cholesterol.
Castaneda's case underscores many of Healthy San Francisco's strengths -- but also what critics point to as a key weakness.
Even before the program began in 2007, Castaneda could have gone to the same clinic, operated by the city's Department of Public Health, and paid for care on a sliding scale.
Some argue that the program is simply a repackaging of the city's existing clinic network, and they wonder why business owners are on the hook for healthcare costs to support it when they were not before.
Since 2008, private employers here with 20 or more on the payroll have been required to spend a minimum amount on healthcare coverage for their workers. They can fulfill that obligation by offering insurance, selecting Healthy San Francisco or paying into a medical reimbursement or health savings account.
Businesses with 20 to 99 workers must pay $1.23 per hour per employee for coverage; those with 100 or more must pay $1.85 per hour. Healthy San Francisco costs about $125 million annually, of which about $14 million comes from employers.