Universal Access to Care: Healthy San Francisco American Public Health Association

1. Universal Access to Care: Healthy San Francisco American Public Health Association 136th Annual Meeting – San Diego, CA Tangerine Brigham, Director of Healthy San Francisco San Francisco Department of Public Health October 28, 2008

2. Presenter Disclosures Tangerine M. Brigham No relationships to disclose The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:

3. The Problem • Magnitude of problem: • 45 million uninsured in United States • 6.5 million uninsured in California • 73,000 uninsured adults in San Francisco • Uninsured persons have: • Less access to medical care • Present for care at later stages of illness • Greater mortality and morbidity due to illness • Fragmented health care delivery system

4. San Francisco’s Response: Universal Health Care Access • Health Care Security Ordinance: • Employer Spending Requirement: Requires certain employers to make health care expenditure on behalf of designated employees. Implemented January 9, 2008. • Healthy San Francisco Program: Universal health care access program for uninsured residents. Debuted July 2, 2007 and City-wide implementation September 17, 2007.

5. Healthy San Francisco Program

6. Healthy San Francisco (HSF) • Provides health care for uninsured San Francisco adults (18 – 64 years old), regardless of: • Employment • Immigration status • Pre-existing conditions • Income level • Offers comprehensive, affordable health care services • Is not a health insurance plan/product • Restructures County indigent health system to encourage preventive care and continuity in primary care • Participants must be ineligible for publicly-funded health insurance

7. For Participants, HSF is an Organized Health Care Program • Select and receive primary care medical home • Streamlines the eligibility and enrollment • Accessible and clear information on services and the costs • Coordinated health care delivery network of providers • Customer service (e.g., call center, HSF ID card, newsletter)

8. HSF Services

9. HSF Provider Network • Primary Care Medical Homes • 14 public health clinics • 8 private non-profit community clinics (13 different locations) • 1 private, non-profit hospital-affiliated clinic • 1 private physicians association • Hospitals • San Francisco General Hospital (public-County) • Hospitals linked to specific medical homes • California Pacific Medical Center (private, non-profit) • Saint Francis (private, non-profit) • St. Mary’s (private, non-profit) • Chinese Hospital (private, non-profit) • Hospitals providing specific services • Univ. of CA San Francisco (public-State) – Radiologic

10. HSF Population and Enrollment • Estimated uninsured adults: 73,000 (2005 CHIS) • Expected enrollment: 60,000 • Currently enrollment (10/08): 31,000 • Phased enrollment strategy – focuses on those with lowest income first • Over 100 HSF application assistors using One-e-App •  35,000 HSF applications processed • 5% of all applications (9% of all applicants) processed are for other health programs

11. HSF Participant Demographics • 74% incomes below 100% FPL; 26% above 100% FPL • 51% male; 49% female • 38% Asian/PI; 24% Hispanic; 16% White; 9% Afr-Amer.; 2% Other; 11% Not Provided • 8% under 25 years old; 65% b/w 25 - 54 years of age; 27% b/w 55 - 64 years of age

12. HSF Fee Structure • Participants pay: • participation fee to remain enrolled in program • point-of-service fees when accessing services • cost of care delivered outside HSF provider network • Affordability impacts access – fees are tied to income and family size • Subsidy to those with incomes at or below 500% FPL • Fees are less than 5% of a household income

13. HSF Funding • Contributions from: • Government • City & County (redirecting existing local dollars) • State/Federal (existing funds to serve uninsured) • Federal (Health Care Coverage Initiative award) • Participants • Employers

14. Employer Spending Requirement (ESR) • San Francisco employers are required to make health care expenditures. Can elect to: • Offer health insurance • Give Health Savings Accounts • Reimburse employees for expenses • Provide health care services • Offer the City Option (incls. Healthy San Francisco) • Challenged by Golden Gate Restaurant Ass’n • Employer Spending Requirement went into effect on January 9, 2008

15. Employers are Selecting City Option • If an employer selects City Option, then their employee receives either: • Healthy San Francisco or • Medical Reimbursement Account • To date, over 1,000 employers have selected the City Option • In total, $18.5 million in health care expenditures committed for 27,500 employees • One-half potentially eligible for HSF • One-half eligible to receive a MRA

16. INTERSECTING POLICY WITH OPERATIONS

17. Moving HSF Policy Objective Toward Reality • A policy isn’t a program, a local ordinance isn’t a program • Pushing operations, technology, our staff to achieve the policy objective • Crafting rules, regulations, processes, procedures, structure, etc. that take into account the existing infrastructure of your system(s)

18. Context for HSF Development • Aggressive timeline for HSF implementation • Coordination across multiple entities • Three technology partners • Third-Party Administrator (San Francisco Health Plan) • Two other City/County agencies • San Francisco Community Clinic Consortium • Highly visible program with significant public interest • GGRA Lawsuit

19. Lessons Learned • Manage change and expectations – frequent and consistent messaging required • Be clear about trade-offs – clarify prioritization since everything cannot be achieved • Clearly define program needs – designing program and developing technology simultaneously can create inefficiencies • Phase implementation – pilot and get the “kinks out” • High level of resources – extensive level of resources pre/post implementation • Linking programs and operational activities is complicated – more interfaces  more complex systems  more opportunities for system “glitches”

20. Replicability in Other Communities

21. Factors in San Francisco’s Implementation • San Francisco’s environment has made effort achievable • Political will and leadership • Public support for addressing problem • Financial resources available to leverage • Safety net providers serving uninsured • Geographic boundaries • Implementation has gone relatively smoothly • Too early to say if HSF is a success on all measures – program evaluation needed

22. HSF Evaluation Components • Participation • Access • Quality • Utilization • Financial viability • Replicability

23. Generalizable Features of HealthySan Francisco • Focus on primary care home to reduce duplication and improve coordination • Centralized eligibility system to maximize public entitlement and increase coordination of benefits • Centralized system of record creates accountability and comprehensive database for planning & evaluation purposes • Non-insurance (care) model potentially results in lower costs and leverages federal/state funds for localities • Establishment of predictable, affordable participation fees; may not be viewed as charity by participants • Public-private partnership maximizes available resources