A tale of two cities, health care edition: Uninsured in Oakland and San Francisco
on December 21, 2009
This the first of two stories on health care reform. A team of Oakland North reporters also looked at how the House health care bill could affect Oakland residents.
Meet Alessandra Chesley, a 26-year-old with a good job as a site coordinator for the Boys & Girls Club of San Leandro. She earns between $30,000 and $40,000 a year. This past August, her position was reclassified—she kept the job, which she loves, but in the reorganization she lost her company-provided health benefits.
If she lived across the bay, in San Francisco, here’s what probably would have happened next:
She’d qualify for Healthy San Francisco, the city’s health care program. That would allow Chesley access to a city clinic, a primary care physician, and hospital services, regardless of any pre-existing condition or immigration status. She would have to pay only a quarterly enrollment fee to participate, along with a small co-payment for each visit to a doctor.
In the midst of the national debate about health care—who deserves it, who should pay for it, how it should be provided—Healthy San Francisco is one delivery model many people are examining. This controversial but so far successful program offers health care services to uninsured, low-to-moderate income residents of San Francisco.
Too bad Chesley lives in Oakland.
Chesley isn’t without options—not now, anyway. When her employer stopped providing her insurance benefits, she opted for coverage under COBRA (the Consolidated Omnibus Budget Reconciliation Act), the federal law that allows individuals to keep paying on their own for health benefits formerly provided by an employer. She now pays $224 per month to continue receiving the health coverage she lost.
But COBRA only gives her 18 months of coverage. And Chesley’s got a complication; she contracted viral meningitis encephalitis while working in Europe nearly three years ago. When she returned to the U.S., before she got her Boys & Girls Club job, she applied for private health insurance. She was denied, because her illness qualified her as having a pre-existing condition.
As it happens, her initial meningitis treatment, under Austria’s national health care system, cost Chesley only a few hundred dollars. “Socialized medicine saved my life,” she said. “I came back to my own country and was denied for medical insurance.”
Chesley’s situation, like that of many thousands of others whose health care access is limited by income, employment status or a pre-existing condition, begs the question: If San Francisco can start up its own municipal health care program, why aren’t there others around the Bay Area? What are the possibilities for a comparable program called Healthy Oakland?
How Healthy San Francisco works: The city-county advantage
San Francisco has certain luxuries few other cities in the country can claim. It is California’s only consolidated city–county, which means its city and county governments are unified. The city is also geographically contained—at 47 square miles, and with only 800,000 residents, it isn’t hard to offer health care services in locations accessible to residents in every neighborhood.
When city leaders decided three years ago to develop a health care program for all San Francisco’s uninsured, they looked to the well-established county health care program. The county system has several public health clinics and a public hospital, which were already serving many uninsured, low-income individuals. “The key thing to stress, from our vantage point, is [the program] is successful because we had this infrastructure in place to support the uninsured prior to Healthy San Francisco,” said Lindsey Angelats, senior health program planner at Healthy San Francisco.
Across the bay, Oakland is San Francisco’s closest Alameda County neighbor, especially in terms of size—Oakland is only slightly larger than San Francisco, at 56 square miles. But while Oakland is Alameda County’s most populated city, only 400,000 people call it home. It is also one of 14 cities in the county. That means 14 different city councils must agree how to serve the county’s nearly 1.5 million people.
That’s part of the answer why there’s no Healthy Oakland initiative.
Each California county is required by law to provide its neediest residents with assistance programs, health care chief among them. In 2006, San Francisco’s Board of Supervisors was able with one new ordinance to turn the city and county’s existing program into Healthy San Francisco—to provide all uninsured residents access to health care. The program began in July 2007. It now serves nearly 50,000 uninsured low- and middle-income residents of San Francisco, providing them a medical home and access to regular health care over the last two years.
It’s not an insurance plan, experts point out. Healthy San Francisco offers care only within the city limits; people who participate don’t have coverage if they need medical help outside the city. It provides medical care services at 27 clinics and four hospitals around the city, including primary and specialty care. Services labeled “non-medical”—such as dental, vision and acupuncture—are excluded.
To be eligible for Healthy San Francisco, one must be a resident of San Francisco, be ineligible for any other federal health program (such as Medicare), and have been uninsured for at least 90 days. Income eligibility is based on the federal poverty level, a national standard set by the Department of Health and Human Services. In San Francisco, people who earn up to five times the federal poverty level—that means $54,150 for a single person, $110,250 for a family of four—are eligible to enroll in Healthy San Francisco.
By comparison, many federal and county assistance programs in California have much tighter eligibility rules for their programs, limiting them to people at no more than twice the federal poverty level. That makes Healthy San Francisco one of the broadest-reaching programs in the country.
The County of San Francisco continues to receive federal and state money and contribute county funds to Healthy San Francisco, just as it did for its preceding county health care program. But the supervisors-approved measure that created Healthy San Francisco also requires employers to contribute a certain dollar amount per employee per hour worked if the business meets a city-determined employee quota. (For-profit businesses must have at least 20 employees; nonprofits, 50.)
Most people admitted to the program must pay a part of their premium every quarter, and co-pay when they receive services. Both payments are set on a sliding scale to reflect a person’s income: If Chesley could participate in Healthy San Francisco, she would most likely pay $150 each quarter, with co-payments ranging from $5 to $50 per visit, depending on the kind of medical care she received.
Many professionals have praised the Healthy San Francisco program since its inception. President Obama referred to the program in a speech to U.S. mayors last February, praising San Francisco Mayor Gavin Newsom for “ensuring that those in need get [health care].” Despite a weak economy, the program continues to add between 500 and 1,000 new participants each month, moving closer to reaching all 60,000 of the uninsured in San Francisco. “Healthy San Francisco is one of the mayor’s key priorities right now,” Angelats said.
But not everything has run smoothly for the program in the last two years. The biggest obstacle, still ongoing, has been a lawsuit filed by the Golden Gate Restaurant Association, a nonprofit trade group. The association argued in its suit that forcing employers to pay into the city’s program violates federal law. “It’s absolutely a back-breaker for our industry,” said Kevin Westlye, the association’s executive director. “This is a survival issue.”
A federal court initially upheld the restaurant association’s position, but an appellate court overturned that ruling in 2008, and the employer mandate went into effect. A new appeal has been sent to the U.S. Supreme Court, but so far, there has been no word as to whether the court will hear the case.
Westlye said cost containment is a large concern for restaurants and other businesses. He is worried that employer contribution requirements will rise once the lawsuit’s outcome is decided.
These concerns would likely be amplified in Oakland, a city that has more than 63,000 uninsured residents and no public health department of its own.
Alameda County’s existing resources, and the daunting cost of expansion
Alameda County does offer health services to the poor, as all California counties are required to do. The county’s two programs just aren’t widely publicized. The first, called the County Medically Indigent Services Plan, serves just under a third of Alameda County’s 196,000 uninsured residents. County residents are eligible if their incomes are at or below twice federal poverty level and are not eligible for other federal health programs. Like Healthy San Francisco, the program provides medical services in the county hospital and clinics: the Alameda County Medical Center, which includes Highland Hospital; and nine community clinics. Dental and vision services, among others deemed non-medical, were cut from the Indigent Services Plan’s budget last summer.
The second program, Alameda County Excellence, is a disease management plan for people who are eligible for the county’s indigent services program and have a diagnosed chronic medical ailment like congestive heart failure, diabetes or asthma.
Alameda County spends nearly $102 million each year on thsee programs, almost $25 million less than San Francisco currently spends on Healthy San Francisco. About half the Alameda County participants live in Oakland.
A group of Alameda County government, medical and social agency leaders has explored the notion of a Healthy San Francisco parallel that might extend throughout Alameda County. Two plans providing health coverage to children and adults were examined—one, a full insurance plan; the other, a limited-by-geography plan similar to Healthy San Francisco.
The additional costs for the plans, depending on how such a program might be structured, ranged from $50 million to more than $750 million per year. It’s money the county simply doesn’t have. “I heard this great line once,” said Alex Briscoe, interim director of the Alameda County Health Care Services Agency, the department that runs the county health care programs. “Alameda County has San Francisco’s politics, Los Angeles’s problems and Fresno’s resources.”
Funding a new program isn’t the only deterrent for the county. For a plan like Healthy San Francisco to succeed, Alameda County’s current health care delivery system—how it provides health services to its residents—would need to be overhauled. “The health care debate is largely a discussion about finance and insurance,” Briscoe said. “It’s missing the point that the system is broken, that costs are rising way faster. You have to re-engineer how services are delivered.”
In order to serve Alameda County’s large uninsured population, Briscoe would like to add additional services to the county’s hospital and clinics—acute care centers, non-traditional health care sites like schools and a 24/7 nurse hotline—to help residents manage and maintain their own preventive care routines. This would make medical care available to people before they become very sick, which would cut down on emergency room visits—the most common and expensive way the county cares for the uninsured who don’t participate in the county’s current health care programs.
Much of what will happen to Alameda County’s proposed health care service programs depends on what is passed in Congress this winter. Briscoe said he understands that any universal health care implemented in Alameda County will only happen with “significant financial assistance.” He and other county officials are closely watching the congressional health care debates to see what will eventually be promised at the county and city level to cover the uninsured. “We would love to do a Healthy San Francisco program,” Briscoe said. “With federal health care reform, we’ll be close.”
Briscoe and other county leaders envision a universal plan for Alameda County within the next five years, but he said he won’t be ultimately satisfied with a geographically limiting plan. “Healthy San Francisco is a stopgap measure,” he said. “The future of health care isn’t a local indigent health program that is geographically restricted. It’s to have full health coverage for everybody.”
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