San Francisco: Healthcare for the Working Poor

HEALTHY SAN FRANCISCO PROGRAM – HEALTHCARE FOR THE WORKING POOR: IS IT FEASIBLE?

Our presidential election is only days away, 48 million people in America are uninsured and healthcare costs are rising two to three times faster than our nation's GDP. Where will America's healthcare system be in five years? Welcome to ReachMD's monthly series focused on public health policy. This month we explore the many questions facing healthcare today.

DR. MICHAEL GREENBERG:

Healthcare for the working poor. Is it possible? Can a major American city afford it? Both San Francisco and an astonishing woman with an unusual name, says yes and yes. You are listening to ReachMD XM157, the channel for medical professionals.

Welcome to the Clinician's Roundtable. I am Dr. Michael Greenberg, your host, and with us today is Tangerine Brigham, Deputy Director of Health at the San Francisco Department of Public Health and Director of Healthy San Francisco. Welcome Tangerine.

TANGERINE BRIGHAM:

Thank you Michael.

DR. MICHAEL GREENBERG:

Let's talk about the Healthy San Francisco Program. Give to us in a nutshell of what it is? It is not an insurance plan. It is a medical home plan. Tell us about it.

TANGERINE BRIGHAM:

Sure. The medical home is the centerpiece for Healthy San Francisco. It's the notion that an individual have a usual source of care and a place to good care on a regular basis as apposed to going to an emergency room or urgent care to get services. They are connected with a provider in a clinic that focuses on primary care, focuses on preventative care and when that individual needs access to specialty services or diagnostic services or pharmacy services, that provider who that person has developed a relationship with, can facilitate that person's access to this and we know that individuals who are uninsured don't have this and as a result, they have to navigate a very difficult system in order to get just basic services, which is costly and inefficient.

DR. MICHAEL GREENBERG:

Now, we are all used to a healthcare system in America where we wait till we get sick and then we show up in the hospital or we show up at a doctor's office with a problem. I keep seeing in all of your literature and you keeping talking about preventative care. How does the program push this or urge people to get preventative care, because from some of the shows we have done in the past, a number of medical experts say that if we could do preventative care, we could cut the healthcare bill down in this country tremendously.

TANGERINE BRIGHAM:

I think that's absolutely right, Michael. One of things we are doing is we have a newsletter and one of our first newsletters that goes out to our clinicians and to our participants, really focuses on preventative health. So we had a whole issue because of our population on Hep B and the importance of getting Hep B screening. One of the things we are looking at is focusing on issues merging our public health role, as we are Public Health Department, and infusing that in Healthy San Francisco, so we have done a lot of work with smoking cessation, those kinds of things, but we do recognize that prevention is in many parts a behavior change and while individuals are really good starting behavior changes in the beginning of the year, say “with New Year's resolution, I am going to eat better and exercise more,” by the time spring comes around, they are forgotten.

DR. MICHAEL GREENBERG:

No, it is January 2nd. By the time January 2nd comes around, you quit the gym membership.

TANGERINE BRIGHAM:

Exactly. Exactly and so one of the things we are doing is sort of continually infusing that message not only through publications we send out to our members, but quite frankly through our clinicians and we hope that by people having a medical home and doing personal relationships, we can focus that better but we recognize that it will take time to get people to really focus on prevention and so we know it's not going to happen overnight.

DR. MICHAEL GREENBERG:

That's where we need to go with our whole healthcare system. Now, how is this funded? People pick co-pays from what I understand from your website.

TANGERINE BRIGHAM:

Sure. The bulk of the funding is actually public funding, be either city and county funding, state funding, or local funding for Healthy San Francisco. In addition, people pay participation fees and point of service fees and that has been no different than what the department has done for almost two decades, but one of things that is important to recognize is that the fees are designed to be affordable so that they don't impede access. So no individual pays more than 5% of their annual income on either the quarterly participation fee or on point of service fees to access the program and to give you a sense of how much the fees are, let us take one person who makes between say 10,000 and 20,000 dollars a year; so they are between 101% and 200% of the federal popu level. The cost of Healthy San Francisco in terms of participation we think on a quarterly basis is about 675 dollars. We think that on average someone will use that amount of healthcare cost. In healthy San Francisco, someone earning between 10,000 and 20,000 dollars a year would only pay 60 dollars a quarter. They are not paying 675 dollars a quarter. So, they receive a subsidy valued at over 600 dollars to make it affordable for them. It will provide an inducement for them to participate.

DR. MICHAEL GREENBERG:

Can they use the system anytime they want, I mean can they can go to the doctor at will?

TANGERINE BRIGHAM:

Well, they will select a primary care medical home. One of the things that we believe is important is a person's selection of a primary care medical home and they will select that home and then if they need to go to that primary care medical home which is a clinic and there are providers in that clinic, they will make an appointment and they can go to that clinic and see that provider. Now if they need to see a specialist, generally they will have to go to their medical home first to be referred to a specialist.

DR. MICHAEL GREENBERG:

So, Tangerine, I have noticed that the covered and noncovered sections are only some dental and no vision care included. Do people get any vision care with their eye issues or is it just out of the picture.

TANGERINE BRIGHAM:

First, left me just clarify one thing you said. Actually, Healthy San Francisco does not cover dental or vision. Okay, in terms of vision, we do not cover the manufacturing of eyeglasses. We do have vision services available for those individuals who have diabetes, who are referred to ophthalmology and from ophthalmology one of the recommendations is that the person get glasses, so we do have it within the context of a clinical medical need, but we do not have the ability, just because of funding limitations, to provide general vision for every one in the program, and that is the same quite frankly with dental. We certainly understand the notion of whole health in that physical health, dental and vision are tied together, but our resources did not allow us to really be able to provide a full scope of dental services under Healthy San Francisco. Now, the Department of Public Health does have about four or five clinics in our system where we provide dental services and someone could go access dental services through that mechanism.

DR. MICHAEL GREENBERG:

Let's change topics for a second. You had or may still have a lawsuit against the program because some of your funding comes from employers and there was one employer who was suing saying it couldn't exist with this. Can you discuss that?

TANGERINE BRIGHAM:

It is actually the Golden Gate Restaurant Association which is an association of restaurants in San Francisco that filed a lawsuit in federal court to prevent not the implementation of Healthy San Francisco, but the implication of the employer's spending requirement which is a companion measure of Healthy San Francisco, but two different programs, and they filed the suit on the grounds that it preempted a federal law, the Employee Retirement Income Security Act. The district court ruled in favor of the restaurant association. The city and county then promptly appealed to the Ninth Circuit. The Ninth Circuit ruled in favor of the City and County, which allowed for implementation of the ESR, the employer-spending requirement, in January. In middle of April, both parties were in court again to do the appeal before the Ninth Circuit. The City argued that it believes the employer-spending requirement did not violate federal law. The Golden Gate Restaurant Association argued the opposite. We are stilling waiting for the Ninth Circuit opinion, but in the meantime the employer-spending requirement went into effect and in fact at the end of April, we had more than 500 employers elect Healthy San Francisco to meet the employer's spending requirement. The value of the funding is over 7 million dollars from those employers to provide some type of health benefit for over 16,000 employees.

DR. MICHAEL GREENBERG:

What do your critics say? Is there are downside to this program?

TANGERINE BRIGHAM:

A downside to Healthy San Francisco? I do not know if there have been downsides of a notion of primary care medical homes and expanding access to the uninsured.

DR. MICHAEL GREENBERG:

But you must have some critics.

TANGERINE BRIGHAM:

But I will say, there is the concern about localities doing this in the absence of state reform because in a lot of ways, you really do need state reform and federal reform to really address the uninsured issue. As you noted in the beginning of the program, Healthy San Francisco is not insurance, there is no portability, but it is also true that San Francisco swells during the day because we have many people who work in neighboring counties. The Healthy San Francisco doesn't allow someone who might be covered in our program, a San Francisco resident, who happens to be in Marin County across the Golden Gate Bridge and who happens to get sick, to be covered under Healthy San Francisco. People would argue that, that probably is something that the state or the federal government should address a regional or statewide effort.

DR. MICHAEL GREENBERG:

But at least you are doing something?

TANGERINE BRIGHAM:

Absolutely, and I think that communities such as San Francisco certainly Massachusetts have decided that while it's preferable to have healthcare reform on a federal level in the absence of having it in on the federal level, states and localities have to be something and if we can help push the issue forward by showing what we were able to do with our resources and giving a sense of what works and what doesn't work, I think we are happy to be the guinea pigs to push this effort in a new direction which is more regional, more statewide, or national.

DR. MICHAEL GREENBERG:

Grassroots, I love it. Have other cities approached you to like look at your program and do you think it will spread to other cities?

TANGERINE BRIGHAM:

Well, we have had interest in other cities and other states. For example, I was in New York last week, our health director was in New Orleans last week, he is in Connecticut now. I have spoken to individuals from South Carolina, from Maryland and alike, all interested in doing certain aspects of our program and we recognize that the strategic advantages that exist in San Francisco might not be the same ones that exist in another area. You know, it’s not a sort of a cookie cutter approach to what we are doing, but we certainly believe communities can quite frankly do feasibility analysis of what currently exists to improve their system.

DR. MICHAEL GREENBERG:

Can you share a story or two about people who were helped greatly by this program, are people grateful?

TANGERINE BRIGHAM:

One of the things that occurred during the debut of Healthy San Francisco was that we talked to a few people and asked them “why did you enroll in the program now,” particularly given the fact that the clinic had been in existence since the 1970s and they as individuals had been living in the city for a number of years but for various reasons had not gone, and one of the things that we noted was that for the first time people felt as though the city was creating an effort that was organized, that they felt as though the city was putting out information in a constructive manner in their language that it was clear, that the costs were affordable, and many of the individuals, particularly one woman I am thinking of who was an Asia Pacific islander who had a sick husband. They had tried their traditional eastern medicines, which were helpful, but really didn't address the underlying causes and as a result of this program for the first time, they were going to see a western doctor, and so those kinds of things are really heartening when you really realize that you actually helped someone.

DR. MICHAEL GREENBERG:

You have changed from being quoted charity-type clinic to really giving a program where people have some power, control, and it's got a positive aspect to it, it's healthy.

TANGERINE BRIGHAM:

Oh! absolutely.

DR. MICHAEL GREENBERG:

Tangerine, thanks for being our guest today and for talking to us about the Healthy San Francisco program. I think it is fabulous; we would like to hear more about it in the future.

TANGERINE BRIGHAM:

Absolutely, welcome to come back at any time, Michael.

DR. MICHAEL GREENBERG:

Thank you.

I am Dr. Michael Greenberg and you have been listening to the Clinician's Roundtable on ReachMD XM157, the channel for medical professionals, and we thank you for listening.

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