March 16, 2017 12:01 AM
Could San Franciscofs universal health care model work for all of California?
By Angela Hart
The Sacramento Bee
SAN FRANCISCO - Alice Chen sees a steady stream of patients here, at Zuckerberg San Francisco
General Hospital and Trauma Center – a massive medical campus that serves as the
backbone of the health care delivery system for the cityfs undocumented
population and its poorest residents.
Through focusing on regular checkups and preventative care, Chen says overall
health care costs have ticked down over the past decade, due in large part to
the systemfs ability to divert patients away from costly emergency room visits
and catch health complications before they escalate to severe illness and
That concept is fundamental to Healthy San Francisco, the cityfs universal
health care program adopted a decade ago that covers everyone regardless of
immigration status or ability to pay.
gIt has been transformational in San Francisco,h said Chen, a primary care
doctor and chief medical officer for the San Francisco Health Network. gIt was
really a reimagining of our delivery system that left out uninsured people just
hoping that nothing goes wrong.h
The program, signed into law by Lt. Gov. Gavin Newsom when he was mayor of
San Francisco, is expected to serve as a foundation of Newsomfs political
platform in the 2018 governorfs race to succeed Gov. Jerry Brown. Turmoil in
Washington over House Republicansf proposal to repeal and replace Obamacare has
fueled Newsomfs resolve to adopt universal health care despite several past
failed statewide efforts.
gHealthy San Francisco was a big idea. It was audacious,h Newsom said in an
interview. gAt the time no one thought it could work – even I wasnft
Newsom said the election of President Donald Trump, followed by a Republican
proposal to replace the Affordable Care Act estimated to leave 14 million
Americans uninsured by next year, has created a mandate for California lawmakers
to undertake health care efforts to stem potential losses in coverage.
In California, state Insurance Commissioner Dave Jones estimates that 1.2
million people who receive subsidies through Covered California would lose their
insurance, and 3.7 million low-income people on Medi-Cal would also risk losing
Newsom said he has long envisioned a universal health care model for
California that includes a single-payer system. He strongly supports the
Affordable Care Act but says he recognizes deep flaws that led to rising
premiums, escalating delivery costs and millions of remaining uninsured –
particularly undocumented immigrants.
gThis is not just something Ifve been talking about for 15 years. This is
something we achieved that has remained a demonstrable model for quality,
affordable health care years since Ifve been mayor,h Newsom said. gItfs a point
of passion for me; itfs a point of pride for me during my time as mayor; and
itfs a point of principal. Wefre in a very challenging spot with this pseudo
repeal and replacement of Obamacare.
gHealth care, for me, is the issue of our time,h he said.
If we donft cover undocumented people and others regardless of their income,
we collectively are going to shoulder the expense of these exorbitant health
The law known as Healthy
San Francisco, created in 2007, has not only endured but has been
strengthened under Obamacare. It covers undocumented San Francisco residents and
poor people who donft qualify for Medi-Cal, the statefs low-income health care
program. It also provides financial assistance for those who qualify for
subsidies through Covered California but still canft afford to purchase health
insurance on their own.
gPart of what we got people to understand, through Healthy San Francisco, is
if we donft cover undocumented people and others regardless of their income, we
collectively are going to shoulder the expense of these exorbitant health care
costs,h said Mitch Katz, who now heads one of the nationfs largest county health
agency in Los Angeles but in 2006 was advising Newsom on how to create a
universal health care system.
gWe said, eShouldnft we provide care in a sensible way that gets them into
primary care, rather than the emergency room and waiting for them to develop
advanced diseases?f These are the most expensive ways to care for people.h
Though it is not health insurance and canft be used outside San Francisco,
the program finances health care for residents within the cityfs borders through
a combination of health department funding, fees paid by employers and
sliding-scale payments from patients. It was initially built with substantial
San Francisco general fund money and federal financing.
It centers on the importance of primary care and routine checkups to help
control costs; mandates that employers contribute to their employeesf health
care allows them to pay into a city-run option; and adopted a provision even
before Obamacare that people with pre-existing conditions canft be denied health
care. Patients can use their coverage at the cityfs network of primary care
clinics as well as at public and private hospitals.
Across California, 47 of the statefs 58 counties provide some health care
benefits for undocumented people, but Healthy San Francisco is the most
pioneering because it also included an employer mandate and covered not only
poor people but also those who simply couldnft afford insurance.
gIt is one of if not the most robust safety net programs in the
country,h said Anthony Wright, executive director of Health Access California, an advocacy nonprofit.
The things that make San Francisco unique also helped Newsom and members of
the cityfs Board of Supervisors advance their cause. The network of 14
community-based clinics, from the Tenderloin District in the heart of the city
and from Hunterfs Point to the Sunset, provided critical infrastructure for the
And the cityfs famously fierce liberal spirit, boosted by a politically
progressive majority at the highest ranks of city government, allowed people
like Newsom and other early architects of the program to take a political
They had to contend with the cityfs powerful business industry – restaurants,
Former San Francisco Supervisor Tom Ammiano helped lead the charge to require
employers to contribute. He said he felt emboldened after seeing early political
support in San Francisco following a 2004 statewide referendum asking California
voters if employers should be required to provide health care coverage for their
Proposition 72, backed by health care advocates and powerful
labor unions at the time, had just been defeated at the ballot box. Statewide,
it went down with 50.8 percent of California votes opposed.
But San Francisco voters overwhelmingly backed the idea. There, it got 70
percent of the vote.
gIt was still a bruising battle, but that showed us that the public wanted
this,h said Ammiano, who went on to serve six years in the state Assembly. gI
always had in mind adopting some kind of model for universal care that covered
undocumented people. I knew from my experience as a teacher that we had a very
high immigrant population who contributed to the economic vitality of the
gAnd I saw with the AIDS crisis what happens to people,h said Ammiano, who
lost his longtime partner to the disease. gIt was very personal for me.h
The Health Care Security Ordinance, passed by the board then
later signed by Newsom, withstood prolonged criticism from the cityfs business
community and the Chamber of Commerce, as well as a high-profile lawsuit brought
by the Golden Gate
Restaurant Association, a powerful voice for the cityfs restaurant
gThe restaurant industry was nasty,h Ammiano said. gBut we beat them every
time in court.h
Today the program serves 14,000 San Francisco residents, down from the peak
of 60,000 before the Affordable Care Act went into effect in 2014. It has
remained a critical program, however, for those who still lack health care
access under federal law. Most of those are undocumented people, program
Doctors are increasingly seeing undocumented people skip appointments out of
fear of deportation, Chen said.
gIf youfd asked me six months ago, I would have said we wouldnft need this
anymore because of Californiafs successful implementation of the Affordable Care
Act and because the Legislature wanted to include all undocumented people,h she
said. gBut now itfs going to be critical to continuing to serve that population,
and as a safety net given the tumult and uncertainty at the federal level.
gWe have the structure – though not necessarily the funding – in place to
expand Healthy San Francisco again if we needed to,h Chen said.
Katz, director of Los Angeles Countyfs Department of Health Services who has
adopted a similar universal care program there called My Health LA, said he is working with Newsom to come up with
a statewide proposal that both preserves health care access and expands it in
the future. Hefs also working with former San Francisco health director
Tangerine Brigham and members of the Los Angeles County Board of Supervisors who
are proponents of single-payer health care.
gI have been charged with putting together an outline for what a California
universal health care plan could look like that includes the values of
inclusiveness, providing high-quality care while lowering costs to the system
yet remaining affordable,h Katz said. gIf we can figure out something that can
work in Los Angeles, which has a third of Californiafs population, there is
consensus that we could get it done statewide.h
Learning from experience both in Los Angeles and San Francisco, Katz said any
statewide model will require broad and robust political support in the
Legislature, as well as from dueling interest groups.
gWhen we started Healthy San Francisco, we said, eOf course the county is
going to be the primary financier, but the cost is too great for the county to
do it by itself.f Going forward, itfs that same lesson for California,h Katz
said. gWe have to get employers, we have to get hospitals and pharmaceutical
companies, we have to get counties c only then are we going to be able to solve