Healthy San Francisco

Healthy San Francisco is a health access program launched in 2007 to subsidize medical care for uninsured residents of San Francisco, California.[1] The program's stated objective is to bring universal health care to the city.[2][3] Healthy San Francisco is not a true insurance program, as it does not cover services such as dental and vision care, and only covers services received in the city and county of San Francisco.[4] The program itself acknowledges its limitations, and has stated that "insurance is always a better choice."[4][5] Healthy San Francisco represents the first time a local government has attempted to provide health insurance for all of its constituents.[6] The program is open to low-income city residents over the age of 18 who do not qualify for other public coverage, and who have had no insurance for at least 90 days.[7] Eligibility is not conditional on citizenship, immigration, employment or health status.[7][8] The program covers a range of services, but only pays providers within San Francisco.[4] By July 2010, almost 90% of the uninsured adults in San Francisco — over 50,000 people — had enrolled in Healthy San Francisco.[9]

Health care in the United States
Government Health Programs

Private health coverage

Health care reform law

State level reform
Municipal health coverage


Prior to the implementation of Healthy San Francisco, the city's safety net health care system for the low-income and uninsured consisted of several community health clinics, a public hospital (San Francisco General Hospital), and a citywide managed care plan.[9] In Mayor Gavin Newsom's first term, he worked to extend the city-funded health insurance program, started under Mayor Brown, to young adults, a program that had been previously offered only to children. Newsom's more ambitious plan on healthcare began to take shape in 2007. In his budget proposal for fiscal year 2007-2008, Newsom announced his intention to provide universal health care for all city residents, based on long-time City Supervisor Tom Ammiano's plan. The care would be provided through the San Francisco Health Access Plan also known as Healthy San Francisco.[10][11] The system planned to improve coordination between the current health care safety net, focus on preventive care, and implement information technology through the use of electronic enrollment and referrals.[9][12] Newsom's proposal has prompted Oakland mayor Ron Dellums and San Mateo County's Board of Supervisors to look into possibilities for providing their own taxpayer-subsidized health care.[13][14]

Golden Gate Restaurant Association v. City and County of San Francisco

Healthy San Francisco mandated large businesses to provide health insurance for their employees, or instead either pay into a citywide healthcare fund or contribute to employees' health savings accounts.[4] The Golden Gate Restaurant Association filed a lawsuit seeking to overturn this policy, claiming the employer mandate conflicted with ERISA.[15] The Ninth Circuit Court of Appeals rejected their arguments in May 2009, and an appeal to the U.S. Supreme Court was declined on June 29, 2010, legally clearing the program for continued existence for the foreseeable future.[16][17]

Impact of the Affordable Care Act

The Patient Protection and Affordable Care Act (ACA) was implemented in 2010 and health care exchanges were established in 2013. The 2010 Affordable Care Act also removed categorical eligibility for Medicaid, thus expanding the number of people who could enroll in the public insurance program.[18] As a result, many who previously did not qualify for Medicaid and instead relied on Healthy San Francisco could enroll in Medi-Cal.[18] Approximately half of Healthy San Francisco's 60,000 patients enrolled in 2013 became eligible for Medi-Cal due to this expansion.[19] Another 10,000 or so Healthy San Francisco enrollees were predicted to get health insurance through the Covered California health exchange that was created as part of the Affordable Care Act.[19] A 2011 report found that the passage of the ACA could reduce Healthy San Francisco enrollment by up to 60%.[1]

Although the ACA led to many people becoming insured, there were still millions who were left without health coverage. Today in San Francisco, these patients are still eligible for Healthy San Francisco. These remaining patients include undocumented immigrants, prisoners, people who have lived in the city for less than 5 years and are thus ineligible for Covered California, and people whose incomes are too high above the Federal Poverty Line to qualify for Medi-Cal but not enough to afford private health insurance.[19]


Healthy San Francisco is funded by the city, the federal government, patient co-payments, and fees imposed on San Francisco businesses whose owners who do not follow the mandate to provide health coverage for their employees.[1] The Health Care Security Ordinance included a requirement that employers with more than 20 workers spend at least a minimum amount towards employee health coverage. The minimum payment for 2014 ranges from $1.63 to $2.44 per hour, depending on firm size; for-profit employers with fewer than 20 workers and non-profits with fewer than 50 workers are exempt.[20] Employers can elect to satisfy this requirement by paying into Healthy San Francisco, in which case their workers may apply for the program.[8] As of early May 2008, over 700 employers had decided to participate in the program.[21][22] Early evidence suggest that employers are spending more on health benefits, but some are raising prices and cutting back on hiring.[22][23]

Healthy San Francisco reportedly costs about $140 million per year, which is expected to go down as the 2013-2014 health exchanges start.[19]

Results and Reception

94% of surveyed Healthy San Francisco enrollees reported that they were somewhat or mostly satisfied with the health access program.[24] More than 90% would recommend it to a friend, but only 40% of participants said their care was considerably better since joining the program.[25] Usage of primary and specialty care services among Healthy San Francisco enrollees was similar to that of the uninsured across the state of California.[9]

Much of Healthy San Francisco's positive reception stems from the city's uniquely structured health care safety-net network, consisting of a conglomerate of both public and private hospitals, clinics, and health centers.[9] This collaborative system allows for greater communication between providers and enables patients to access facilities that are equipped to offer the type of care they need, whether that be primary, specialty, or urgent care.[9] The creation of a more coordinated system also led to more efficiency and less redundancy. As more patients became established in primary care medical homes, duplicative services waned.[9]

San Francisco residents who have benefitted from Healthy San Francisco have noted how the program has made them less wary of accessing health care, as previously many of the beneficiaries of Healthy San Francisco did not see a provider regularly due to cost.[26] Healthy San Francisco significantly affected access to ongoing care and chronic disease management for the uninsured, particularly because the Emergency Medical Treatment and Active Labor Act (EMTALA) had previously made emergency care available.[9]

Although Healthy San Francisco does not directly impact those with private or public insurance, studies have found that increasing the proportion of people insured in a community can lead to higher quality of care even for those who are insured, particularly in terms of access to and availability of specialty care.[27]

See also


  1. ^ a b c "Reform Law Could Curb Healthy San Francisco's Enrollment by Up to 60%". California Healthline. April 19, 2011.
  2. ^ "San Francisco's Latest Innovation: Universal Health Care", by Laura A. Locke, Time, June 23, 2006
  3. ^ "What is Healthy San Francisco". Archived from the original on 2007-10-31.
  4. ^ a b c d Sankin, Aaron (2011-11-29). "Healthy San Francisco, The City's Universal Health Care Plan, Finalist For Harvard Prize". Huffington Post. Retrieved 2017-12-08.
  5. ^ "Visitors". Healthy San Francisco.
  6. ^ Sack, Kevin (2007-09-14). "San Francisco to Offer Care for Uninsured Adults". The New York Times. ISSN 0362-4331. Retrieved 2017-10-19.
  7. ^ a b "Are You Eligible?". Healthy San Francisco.
  8. ^ a b "Key Facts: Healthy San Francisco" (PDF). Kaiser Commission on Medicaid and the Uninsured. March 2008. Retrieved 2017-06-21.
  9. ^ a b c d e f g h Katz, Mitchell H.; Brigham, Tangerine M. (2011-02-01). "Transforming A Traditional Safety Net Into A Coordinated Care System: Lessons From Healthy San Francisco". Health Affairs. 30 (2): 237–245. doi:10.1377/hlthaff.2010.0003. ISSN 0278-2715. PMID 21289344.
  10. ^ John Ritter (2006-07-07). "San Francisco may get universal health care". USA Today. Retrieved 2008-03-10.
  11. ^ Laura A. Locke (2006-06-23). "San Francisco's Latest Innovation: Universal Health Care". Time. Retrieved 2008-03-10.
  12. ^ Doug Trapp (2007-08-20). "San Francisco launching universal health care plan". Retrieved 2008-03-10.
  13. ^ Christopher Heredia (2006-06-26). "Dellums considering health care option". San Francisco Chronicle. Retrieved 2008-03-10.
  14. ^ Michelle Durand. "County to study universal health care". San Mateo Daily Journal. Retrieved 2008-03-10.
  15. ^ "Golden Gate Restaurant Association v. City and County of San Francisco: 546 F.3d 639 (9th Cir. 2008) | Berkeley Law". Berkeley Law. Retrieved 2017-10-05.
  16. ^ "Golden Gate Restaurant Ass'n v. City an County of San Francisco" (PDF). United States Court of Appeals for the Ninth Circuit. March 9, 2009.
  17. ^ John Wildermuth (June 29, 2010). "Healthy San Francisco clears last legal hurdle". San Francisco Chronicle.
  18. ^ a b Barr, Donald (2011). Introduction to U.S. Health Policy: The Organization, Financing, and Delivery of Health Care in America. JHU Press. ISBN 1421402971.
  19. ^ a b c d Knight, Heather (2013-10-26). "Healthy S.F. might sicken Tea Partiers". San Francisco Chronicle.
  20. ^ "Health Care Security Ordinance (HCSO)". San Francisco Office of Labor Standards Enforcement.
  21. ^ Wyatt Buchanan, "734 businesses sign up for S.F. health program", San Francisco Chronicle, May 2, 2008
  22. ^ a b "Coverage & Access | Healthy San Francisco Program Prompts Some Companies To Shift Costs to Consumers but Appears Effective", Kaiser Daily Health Policy Report, Kaiser Family Foundation, May 5, 2008
  23. ^ Phred Dvorak, "Firms Adjust to Health-Care Law", The Wall Street Journal, May 5, 2008
  24. ^ "Survey of Healthy San Francisco Participants". The Henry J. Kaiser Family Foundation. 2009-08-02. Retrieved 2017-12-08.
  25. ^ "Healthy San Francisco rates high in satisfaction", by Heather Knight, San Francisco Chronicle, August 26, 2009
  26. ^ Sack, Kevin (2007-09-14). "San Francisco to Offer Care for Uninsured Adults". The New York Times. ISSN 0362-4331. Retrieved 2017-10-19.
  27. ^ Pauly, Mark V.; Pagán, José A. (2007-09-01). "Spillovers And Vulnerability: The Case Of Community Uninsurance". Health Affairs. 26 (5): 1304–1314. doi:10.1377/hlthaff.26.5.1304. ISSN 0278-2715.
Blue Cross Blue Shield Association

Blue Cross Blue Shield Association (BCBSA) is a federation of 36 separate United States health insurance organizations and companies, providing health insurance in the United States to more than 106 million people. Blue Cross was founded in 1929 and became the Blue Cross Association in 1960, while Blue Shield emerged in 1939 and the Blue Shield Association was created in 1948. The two organizations merged in 1982.

In the healthcare insurance industry the organization is known as "The Association" and has two offices in Chicago and Washington. The main office is in Chicago in the Illinois Center at 225 North Michigan Avenue. The Association is the link between all the other Licensees as it controls access to the cross and shield trademarks and the names Blue Cross and Blue Shield. It controls the communications between the different "Plans" that allow all the Licensees to offer national insurance even though each has very defined service areas. The Association also controls the operating policies that each Licensee must follow to be a Licensee.

Dennis Herrera

Dennis Herrera is the elected City Attorney of San Francisco, perhaps best known for his longtime legal advocacy for same-sex marriage in California, including the In re Marriage Cases, 43 Cal.4th 757 (2008), and Hollingsworth v. Perry, 570. U.S. (2013), also known as the legal fight against Proposition 8. He was first elected as City Attorney in 2001, and re-elected without opposition in 2005, 2009, 2013 and 2015. He ran unsuccessfully for Mayor of San Francisco in the 2011 election, finishing third in the City's ranked-choice voting system.

Dirigo Health

The Dirigo Health Agency (sometimes known simply as Dirigo Health) was a government agency run by the state of Maine in the United States. It oversees the state's subsidized health insurance program, DirigoChoice.[1] The program was launched in 2005, and takes its name from the state motto of Maine, Dirigo, which is a Latin phrase meaning "I Lead." The program ended December 31, 2013 with the implementation of the Affordable Care Act (also known as Obamacare).

End Stage Renal Disease Program

In 1972 the United States Congress passed legislation authorizing the End Stage Renal Disease Program (ESRD) under Medicare. Section 299I of Public Law 92-603, passed on October 30, 1972, extended Medicare coverage to Americans if they had stage five chronic kidney disease (CKD) and were otherwise qualified under Medicare's work history requirements. The program's launch was July 1, 1973. Previously only those over 65 could qualify for Medicare benefits. This entitlement is nearly universal, covering over 90% of all U.S. citizens with severe CKD.

Exclusive provider organization

In the United States, an exclusive provider organization (EPO) is a hybrid health insurance plan in which a primary care provider is not necessary, but health care providers must be seen within a predetermined network. Out-of-network care is not provided, and visits require pre-authorization. Doctors are paid as a function of care provided, as opposed to an HMO. Also, the payment scheme is usually fee for service, in contrast to HMOs in which the healthcare provider is paid by capitation and receives a monthly fee, regardless of whether the patient is seen.

Fair Share Health Care Act

Maryland Senate Bill 790, known as the Fair Share Health Care Act, also nicknamed the "Wal-Mart Bill", was a legislative act passed in the state of Maryland in 2005. The act would have required for-profit employers with more than 10,000 workers in the state of Maryland to spend at least 8% of their payroll on employee health benefits or make a contribution to the state's insurance program for the poor. Non-profit employers were required to do the same, but with a lower, 6% benchmark.

The Maryland legislature initially passed the bill on April 5, 2005. Though its supporters contended that it did not single out Wal-Mart, Wal-Mart was the only private, for-profit employer in the state that would have been affected.The bill was vetoed by then-Governor Robert L. Ehrlich On January 12, 2006, the Senate decided to override Ehrlich's veto, thereby passing the act into law.On July 18, 2006, federal judge J. Frederick Motz struck down the law as preempted by ERISA. On January 17, 2007, the United States Court of Appeals for the Fourth Circuit upheld the decision.

Health Reimbursement Account

Health Reimbursement Account is a notional derivative of a Health Reimbursement Arrangement (HRA), a type of US employer-funded health benefit plan that reimburses employees for out-of-pocket medical expenses and, in limited cases, to pay for health insurance plan premiums.Following implementation of the Affordable Care Act, the health plans must be integrated with a qualified employer-sponsored group health insurance plan to avoid excise tax penalties. Using a Health Reimbursement Arrangement yields "tax advantages to offset health care costs" for both employees and employers.

Health maintenance organization

In the United States, a health maintenance organization (HMO) is a medical insurance group that provides health services for a fixed annual fee. It is an organization that provides or arranges managed care for health insurance, self-funded health care benefit plans, individuals, and other entities, acting as a liaison with health care providers (hospitals, doctors, etc.) on a prepaid basis. The Health Maintenance Organization Act of 1973 required employers with 25 or more employees to offer federally certified HMO options if the employer offers traditional healthcare options. Unlike traditional indemnity insurance, an HMO covers care rendered by those doctors and other professionals who have agreed by contract to treat patients in accordance with the HMO's guidelines and restrictions in exchange for a steady stream of customers. HMOs cover emergency care regardless of the health care provider's contracted status.

Healthcare availability for undocumented immigrants in the United States

In the United States, while healthcare can, in theory, cost less for undocumented immigrants than for legal immigrants and other U.S. citizens, significant barriers to health care face undocumented immigrants, including low socioeconomic status, difficulty negotiating time off of work, lack of transportation and language

barriers. Having medical insurance coverage—whether private or through Medicaid—significantly influences the actual utilization of healthcare services.Only a handful of municipalities in the United States offer health care coverage for undocumented immigrants, including Los Angeles County's My Health LA program, and San Francisco's Healthy San Francisco.

Healthy Howard

Healthy Howard is a county-sponsored health care program offered to certain uninsured residents of Howard County, Maryland. The program, which provides doctors visits and prescription drugs, has been nationally hailed as a model to offer health care to local lower income people without health insurance.The program started on October 1, 2008 with a plan to accommodate 2,200 people in a salary range of $35,000 to $63,600 for a family of four. Plans were to increase this number by 2000 enrollees each year thereafter.Services are also offered to those who become unemployed.

Independent practice association

In the United States, an independent practice association (IPA) is an association of independent physicians, or other organization that contracts with independent physicians, and provides services to managed care organizations on a negotiated per capita rate, flat retainer fee, or negotiated fee-for-service basis.

Managed care

The term managed care or managed healthcare is used in the United States to describe a group of activities ostensibly intended to reduce the cost of providing for profit health care and providing health insurance while improving the quality of that care ("managed care techniques"). It has become the essentially exclusive system of delivering and receiving American health care since its implementation in the early 1980s, and has been largely unaffected by the Affordable Care Act of 2010.

...intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases. The programs may be provided in a variety of settings, such as Health Maintenance Organizations and Preferred Provider Organizations.

The growth of managed care in the U.S. was spurred by the enactment of the Health Maintenance Organization Act of 1973. While managed care techniques were pioneered by health maintenance organizations, they are now used by a variety of private health benefit programs. Managed care is now nearly ubiquitous in the U.S, but has attracted controversy because it has had mixed results in its overall goal of controlling medical costs. Proponents and critics are also sharply divided on managed care's overall impact on U.S. health care delivery, which ranks among the best in terms of quality but among the worst with regard to access, efficiency, and equity in the developed world.

Medical savings account (United States)

In the United States, a medical savings account (MSA) refers to a medical savings account program, generally associated with self-employed individuals, in which tax-deferred deposits can be made for medical expenses. Withdrawals from the MSA are tax-free if used to pay for qualified medical expenses. The MSA must be coupled with a high-deductible health plan (HDHP). Withdrawals from MSA go toward paying the deductible expenses in a given year. MSA account funds can cover expenses related to most forms of health care, disability, dental care, vision care, and long-term care, whether the expenses were billed through the qualifying insurance or otherwise.Once the plan deductible is met in a given year, the HDHP will pay any remaining covered medical expenses in that year. If there are funds remaining in the MSA at the end of the year, the funds can either roll over for the following year or can be withdrawn as taxable income.MSAs are similar to health savings accounts (HSAs), which were established as part of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

Military Health System

The Military Health System (MHS) is the enterprise within the United States Department of Defense that provides health care to active duty and retired U.S. Military personnel and their dependents. Its mission is to provide health support for the full range of military operations and sustain the health of all who are entrusted to MHS care.Its primary mission is to maintain the health of military personnel, so they can carry out their military missions; and to deliver health care during wartime. Often described as the medical readiness mission, this effort involves medical testing and screening of recruits, emergency medical treatment of troops involved in hostilities, and the maintenance of physical standards of those in the armed services.

The MHS also provides, where space is available, health care to dependents of active duty service members, to retirees and their dependents, and to some former spouses. Such care has been made available since 1966, (with certain limitations and co-payments), through the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) and its successor, TRICARE. In October 2001, TRICARE benefits were extended to retirees and their dependents aged 65 and over. In 2013, the Defense Health Agency replaced TRICARE.

The MHS has a $50 billion budget and serves about 10 million beneficiaries, including active duty personnel and their families and retirees and their families. The actual cost of having a government-run health care system for the military is higher because the wages and benefits paid for military personnel who work for the MHS and the retirees who formerly worked for it, is not included in the budget. MHS employs more than 137,000 in 65 hospitals, 412 clinics, and 414 dental clinics at facilities across the nation and around the world, as well as in contingency and combat-theater operations worldwide.

My Health LA

My Health LA (abbreviated MHLA) is a no-cost health care program for low-income Los Angeles County residents, designed to benefit between 400,000 and 700,000 LA County residents who are ineligible for Medi-Cal, most of those being undocumented immigrants.The program establishes a network of community clinics who provide primary care needs for enrolled patients under the medical home model, with incentives to providers to coordinate care and manage utilization. The Los Angeles County Board of Supervisors allocated US$55,000,000 in annual funding to support the program.The program, which was launched on October 1, 2014, is administered by the Los Angeles County Department of Health Services. MHLA succeeded the County's previous program, Healthy Way LA. As of September 2016, MHLA has enrolled 147,314 patients.

Preferred provider organization

In health insurance in the United States, a preferred provider organization (PPO), sometimes referred to as a participating provider organization or preferred provider option, is a managed care organization of medical doctors, hospitals, and other health care providers who have agreed with an insurer or a third-party administrator to provide health care at reduced rates to the top insurer's or administrator's clients.

Program of All-Inclusive Care for the Elderly

Program of All-inclusive Care for the Elderly (PACE) are programs within the United States that provide comprehensive health services for individuals age 55 and over who are sufficiently frail to be categorized as "nursing home eligible" by their state's Medicaid program. Eligibility for PACE requires that individuals be 55 years old or older, certified by the state to need nursing home-level care, reside near a PACE program, and able to live safely in the community. Services include primary and specialty medical care, nursing, social services, therapies (occupational, physical, speech, recreation, etc.), pharmaceuticals, day health center services, home care, health-related transportation, minor modification to the home to accommodate disabilities, and anything else the program determines is medically necessary to maximize a member's health.

SustiNet (Connecticut)

SustiNet is a Connecticut health care plan passed into law in July, 2009. Its goal is to provide affordable health care coverage to 98% of Connecticut residents by 2014. The name SustiNet derives from the motto of the State of Connecticut: "Qui transtulit sustinet." (Latin: "[He] Who Transplanted [Still] Sustains").

Vermont health care reform

In 2011, the Vermont state government enacted a law functionally establishing the first state-level single-payer health care system in the United States. Green Mountain Care, established by the passage of H.202, creates a system in the state where Vermonters receive universal health care coverage as well as technological improvements to the existing system.

On December 17, 2014, Vermont abandoned its plan for universal health care, citing the taxes required of smaller businesses within the state.

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