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David Baxter

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San Francisco to Offer Care for Uninsured Adults
By KEVIN SACK, New York Times
September 14, 2007

SAN FRANCISCO ? Since contracting polio at age 2, Yan Ling Ho has lived with pain for most of her 52 years. After she immigrated here from Hong Kong last year, the soreness in her back and joints proved too debilitating for her to work.

That also meant she did not have health insurance. Not wanting to burden her daughter, who was already paying her living expenses, Ms. Ho delayed doctors? visits and battled her misery with over-the-counter medications.

?Sometimes the pain was so bad, I would just cry,? she said. ?I didn?t know what else to do.?

Last month, unable to bear her discomfort any longer, Ms. Ho went to North East Medical Services, a nonprofit community clinic on the edge of Chinatown, and discovered to her delight that she qualified for a new program that offers free or subsidized health care to all 82,000 San Francisco adults without insurance.

The initiative, known as Healthy San Francisco, is the first effort by a locality to guarantee care to all of its uninsured, and it represents the latest attempt by state and local governments to patch a inadequate federal system.

It is financed mostly by the city, which is gambling that it can provide universal and sensibly managed care to the uninsured for about the amount being spent on their treatment now, often in emergency rooms.

After a two-month trial at two clinics in Chinatown, the program is scheduled to expand citywide to 20 more locations on Sept. 17.

Whether such a program might be replicated elsewhere is difficult to assess. In addition to its unique political culture, San Francisco, with a population of about 750,000, has the advantages of compact geography, a unified city-county government, an extensive network of public and community clinics and a relatively small number of uninsured adults. Virtually all the city?s children are covered by private insurance or government plans.

At the bustling North East Medical Services clinic, where the staff and the signs are multilingual, doctors and nurses are trying to build trust with patients who may have last sought treatment from an herbalist. Families crowd the elevators, as teenagers help parents and grandparents navigate the system. Patients like Ms. Ho say they hope their access to the clinic?s services will bring them independence, and a chance to work.

Healthy San Francisco provides uninsured San Franciscans with access to 14 city health clinics and 8 affiliated community clinics, with an emphasis on prevention and managing chronic disease. It is, however, not the same as insurance because it does not cover residents once they leave the city.

After a phased start-up, the city plans to bring private medical networks into the program next year, expanding the choice of doctors. Until November, enrollment will be limited to those living below the federal poverty line ($10,210 for a single person; $20,650 for a family of four). Then it will open to any resident who has been uninsured for at least 90 days, regardless of income or immigration status.

Only then will city officials learn whether the program appeals to middle-class workers, who make up a growing share of the uninsured. And only then can they test whether San Francisco has the medical infrastructure to handle the desired increase in demand, and to do so without raising taxes.

So far, enrollment has exceeded expectations. The city projected that 600 to 1,000 people would sign up by the end of August. More than 1,300 did, even though officials have done little marketing. They hope to enroll about 45,000 people ? more than half the city?s uninsured ? in the first year. Some clinics are adding night hours and small numbers of workers.

?We really didn?t know what the interest level would be, so we?re very pleased,? said Mayor Gavin Newsom. ?At the same time, we don?t want overexuberance yet because we don?t want to fall of our own weight.?

At the two pilot clinics, efforts are first made to qualify patients for Medicaid or other state and federal insurance programs. Those left over receive a Healthy San Francisco card that makes them eligible for primary care, dental exams, mental health and substance abuse services, hospitalization, radiology and prescription drugs.

Because the coverage is not portable, officials believe that people with private insurance will have little incentive to drop their policies to take advantage of the city?s cut-rate services.

Like Ms. Ho, many of those enrolling were already using the city?s health clinics ? or the emergency room at San Francisco General Hospital ? in times of acute need, like an asthma attack or stroke. About 57,000 of the 82,000 uninsured San Franciscans have used the city?s health system at some point.

But the new program hopes to persuade them to become regulars who regard their neighborhood clinic as a medical home. Once enrolled, patients are assigned a physician and encouraged to get blood pressure checks, mammograms and other screenings.

?We had a system that was not a system, and was based on episodic visits for chronic and acute care,? said Dr. Mitchell H. Katz, the city health director. ?The idea that you should come get a cholesterol test, that didn?t happen.?

Nor was it uncommon for patients to ignore doctors? orders because of cost. Before the program started in July, a clinic doctor had ordered X-rays and blood tests for Ms. Ho, but she never got them.
 

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