Jose Ng knows all the hesitations and hiccups that newly arrived immigrants settling in San Francisco might experience when signing up for health care.
As the immigrant rights program manager for Chinese for Affirmative Action, Ng helps new arrivals, mostly from China, register for programs that can help. One of them, Healthy San Francisco, offers health care services to uninsured people living in San Francisco — regardless of their immigration status — who don’t qualify for public insurance programs like Medi-Cal or Medicare.
San Francisco was a pioneer in offering health coverage to all its residents with the expansion of Healthy SF by former Mayor Gavin Newsom in 2008. And now, as governor of California, Newsom has his sights set on taking the idea to the state level by ensuring undocumented Californians of all ages can sign up for the state’s low-income health care plan, Medi-Cal.
But that’s left some locals, policy experts and immigration advocates wondering what such a statewide health insurance plan will mean for options that San Francisco already offers.
“We really appreciate the governor taking such a bold position and ensuring all Californians can have health care access,” said Ng. “In S.F., I wonder how it will play out. Will that be overlapping?”
As of Jan. 1, about 16,000 San Franciscans were enrolled in Healthy SF, according to the San Francisco Department of Public Health. It’s not an insurance plan, and the program’s brochure states: “Health insurance is a better option than Healthy San Francisco.” Instead, Healthy SF provides more affordable, albeit limited, health services for extremely low-income residents.
Still, some health policy experts question the locally funded program in a world where all Californians have an insurance option.
“I’m guessing that if Newsom’s plan that everyone in our state can get coverage, if everything goes according to plan, Healthy SF doesn’t need to do it anymore,” said Robin Flagg, a public health policy lecturer at the University of California, Berkeley and San Francisco State University. “Why should they (the city and local businesses) pay for health care if their residents can get health care from the state?”
One could argue that’s a success story for Healthy SF, Flagg added.
Quality of Access
But The City’s public health officials and immigration rights advocates agree that truly universal coverage is still years away, and some individuals may fall between the cracks even with a Medi-Cal expansion, such as those who make just above the income threshold to qualify.
“If this proposal is implemented, most Healthy SF participants would become eligible for Medi-Cal and therefore no longer eligible for Healthy SF,” said Alice Kurniadi, a program manager with SFDPH. “However, Healthy SF would still be an option for individuals who are not eligible for Medi-Cal, namely those whose income is above the current Medi-Cal maximum of 138% federal poverty level.”
Healthy SF could remain an option for San Franciscans who are “predominantly unable to purchase insurance due to cost,” Kurniadi said. “Undocumented residents would face higher insurance costs because they are unable to take advantage of subsidized insurance through Covered California.”
Sarah Dar, director of health and public benefits policy at the California Immigrant Policy Center, said her organization is thrilled about the governor’s proposal. But, she adds, “There will definitely still be people who for a number of reasons might not be able to access or afford and still have trouble getting comprehensive health care even when these are in place.”
Others point out that increased access does not necessarily mean equitable access. Healthy SF, for example, provides limited coverage and makes it difficult for users to get access to specialized care that requires referrals. Healthy SF does not cover services such as dental, vision and long-term care.
“What you hear time and time again is primary care providers become the default specialty providers because they have clients who can’t afford and won’t get specialty care. That’s mitigating conditions that need higher care,” said Maria-Elena Young, an assistant professor in public health at UC Merced who studies public health coverage programs such as Healthy SF and My Health LA in Southern California. “With the statewide proposal, it’s full-scope medical service.”
Ng, who coordinates workshops for immigrants on how to sign up for health coverage, has seen some of those shortcomings and other barriers play out up close.
“There’s a lack of information and appropriate language. There are a lot of questions about what it will cover and how much it could cover,” said Ng, adding that many of the individuals he works with come from countries where there are single-payer health systems or all hospitals are run by the government. “It’s even more difficult if you’re undocumented.”
The DPH acknowledges these challenges. “Individuals may be eligible for Healthy SF and are not aware of the program or how to enroll,” said Kurniadi.
Health Care Wars
Across the state, the battle over universal health care in California is currently playing out in the form of two different proposals. One, from Gov. Newsom, comes in the form of a budget allocation that would cover undocumented residents of all ages in the state’s existing public health care system beginning in 2024, and maintain the private marketplace.
The other is a bill, AB 1400, making its way through the legislature that would require creating a single-payer system that would in turn remove copayments and private health insurance companies. Advocates for that system say that it would provide a more equitable quality of care.
Meanwhile, members from The City’s business community have been calling for revisions to The City’s public health care plans long before the recent proposals to extend or even overhaul the state’s health care system.
San Francisco requires employers in The City and at San Francisco International Airport to provide health insurance or health care expenditures on behalf of eligible employees. In 2006, SFDPH created Healthy SF and an employer spending requirement to make health care more widely available for uninsured and undocumented residents. Companies may also choose a privately managed health benefit as an alternative to City Option, in which funds collected on an employee’s account can be used for health insurance premiums, doctor’s office visits, dental services, vision services and prescriptions.
In December, SFDPH reported that there were $104 million in unused funds in a medical reimbursement account, or MRA, a part of City Option.
“I think the program was well-intentioned, but time has proven it to be an utter failure. They should immediately return the unused funds back to the struggling small businesses that paid into it,” said Ben Bleiman, founder of the SF Bar Owner Alliance. “They should also dismantle the program and stop trying to fund sweeping progressive causes on the backs of small businesses.”
DPH officials, however, say there’s still going to be a role for the MRA programs after health care is expanded in California.
“SF MRA would continue to supplement participants’ existing health insurance, similar to how regular FSA programs work together with health insurance,” Kurniadi said. “Enrolled participants can use their MRA to cover out-of-pocket health care expenditures, including insurance premiums.”
Dar of CIPC said programs like Healthy SF have paved the way for health care policy at a state and national level. But she’d like to see The City and others move beyond local solutions to larger gaps in the health care system.
“While we’re glad some counties have forged ahead,” she said, “this Medi-Cal expansion will be a much more equitable way to do this and hopefully those counties can save some money.”