Ever since 50-year-old Liliana Fernandez arrived in the United States, she’s relied on a San Francisco program to provide basic health services for people like her with no other insurance options.
The program, Healthy San Francisco, launched in 2007 as a first-of-its-kind attempt by local government to provide universal health care, though not full coverage. It’s available to low-income adults living in San Francisco ineligible for public coverage and lacking a private plan. It’s also one of a few programs offered to San Francisco workers not covered by their employer.
“I don’t qualify for other health insurance,” said Fernandez, who is undocumented, in Spanish through a translator. “The other insurance they offer, I would have to pay or I simply can’t enroll because I don’t have a valid social security number.”
Options have expanded dramatically since Healthy SF began. Three years after The City launched the program, President Barack Obama signed the Affordable Care Act, a comprehensive health care reform plan to subsidize care for low-to-middle income households.
As the ACA was implemented, enrollment for Healthy SF dropped from a peak of 54,000 and held steady at roughly 13,000. Eligibility for federal and state coverage has expanded little by little, reducing the need for Healthy SF.
“Right when ACA started, the percentage of disenrolled became a lot higher, “ said Alice Kurniadi, Healthy SF manager with the Department of Public Health. “Those are things we feel good about. The Healthy SF program is a program of last resort. It’s great but it’s not full coverage.”
For people like Fernandez, it’s still the only option.
Data obtained and analyzed by the Examiner shows that 9,869 of the 13,824 people enrolled as of September are classified as Hispanic, making up about 71 percent of those served by Healthy SF. While immigration status reporting is incomplete, 8,547 said they were not legal permanent residents. The average age of people who use the program is 44.
Ultimately, people who rely on Healthy SF are low-income, often locked out of other public programs, and may have trouble navigating the cumbersome health system. Until the government finds a way to provide insurance to every single resident, there will be a core group of people who need programs like Healthy SF — a need made clear by the pandemic.
“The numbers are just devastating and the population that is in crisis right now is the Latino community and the low-income community,” said Maria Contreras, a community organizer with Clínica Martín-Baró. “It’s been a battle that’s been on the books for a very long time in terms of having access to health care. It’s now more than ever that we cannot turn away from this.”
Pandemic stress test
Martín-Baró’s volunteer team of medical students are part of the Latino Task Force, created to address the disproportionate impacts of the pandemic.
Testing studies done by the Latino Task Force and the University of California San Francisco have found that among those infected with coronavirus, a disproportionate number are Latino, and many of those reached by researchers didn’t have a primary care provider. Healthy SF can help fill that gap.
“For me, Healthy SF is a tremendous win in so many aspects of our community,” said Edgar Castellanos, another community organizer with Martín-Baró, who is a DACA recipient. “It hits personal. For the longest time, I didn’t have access to health care. It’s a very special program.”
But in helping people apply for benefits such as unemployment insurance, food stamps, and programs including Healthy SF while pushing for pop-up testing sites, task force volunteers also identified barriers to accessing services.
As the free Mission clinic enrolled new patients, Martín-Baró workers found many were previous Healthy SF users who lost access or were unsure of their status with the program. Many had disconnected phones, presumably due to prioritizing food and rent in the face of lost income, which made it difficult for them to get help or for providers to reach out to them.
One patient who still had cell service spent about 45 minutes on the phone multiple times trying to renew, Contreras said.
“In the beginning, we were intaking anyone, but then we realized this was a Healthy SF issue and they should be stepping up,” Castellanos said. “I know that they mean well, but they’re unaware of what’s actually happening in the community.”
During the wave of mass layoffs and subsequent loss of insurance caused by the pandemic, Healthy SF enrollment declined at first. In January, the program had 13,657 patients; by April that went down to 13,130. This may have been linked in part due to the “public charge” rule the Trump administration instituted in February to screen immigrant applications based on whether they are likely to rely on government support, spreading fear of using benefits among immigrant communities. The rule was blocked in December, but the fear remains.
DPH responded to the emergency by initially giving patients with enrollment expiration dates between March and June 90 days to renew; that was eventually increased to 180 days for patients with expiring enrollment until June 2021, as Martín-Baró organizers advocated for a pause throughout the whole pandemic. The department also worked to bring back patients who were booted off the program, which boosted enrollment numbers once again to 13,824 as of September. It’s not clear how much of that boost is due to new interest spurred by the pandemic.
“Since the beginning of the year, there’s been different things working in opposition to each other,” Kurniadi said. “It’s a little bit challenging to understand exactly what’s going on.”
January is also when Californians between the ages of 18 and 26 became eligible for full-scope Medi-Cal, regardless of immigration status. Any subsequent movement of people from Healthy SF to more robust coverage is welcome, Kurniadi added.
Data shows that 20 percent of Healthy SF patients since the program began were tracked as enrolling in public coverage, employer insurance or transitioning to other programs. On the other hand, 59 percent were disenrolled out of simple failure to renew, while 8 percent are noted as not being able to afford the participant fee, which is set based on their income, or not paying the full amount.
Analysis of June 2019 to September 2020 enrollment data found that while some medical homes, or assigned clinics, serving Healthy SF patients saw negligible changes, some had sizable increases.
HealthRIGHT 360’s Haight Ashbury Integrated Care Center more than doubled its Healthy SF patient load, adding 199 new clients under the program. Richard F. Fine People’s Clinic saw a 16 percent increase in patients covered by Healthy SF. The clinic, as well as the Family Health Center that also sees Healthy SF patients, are located at Zuckerberg San Francisco General Hospital, where roughly one-third of program patients go for care.
Mission Neighborhood Health Center’s Excelsior clinic had a 29 percent increase. The Excelsior, Mission, and Bayview Hunters Point neighborhoods, with high numbers of Latino, Black and low-income residents, use Healthy SF at the highest rates.
MNHC CEO Brenda Storey said she’s not sure why the Excelsior clinic saw higher Healthy SF enrollment. However, since the pandemic, MNHC as a whole has enrolled about 1,000 new uninsured patients who have no designated care center, which makes it harder to connect to care when needed. Preventative care is known to be a major force behind better health outcomes.
“One of the things that I think COVID has exposed is really the amount of people in the Latino community that do not have a medical home, which was actually surprising,” Storey said. “One of the goals of the program was to do exactly that, to connect people to medical homes. It just means that we need to increase our efforts of letting people know what clinics are available.”
What patients say
People who use Healthy SF rate it highly. In a limited survey of 39 people conducted by the Examiner at SF General in January and February, 17 people rated it a five out of five when asked how helpful the program is. Another 12 people rated it a four and four people rated it a three.
There are some limitations. Healthy SF user Michelle White said it can take some time to get appointments scheduled, like for an MRI she is awaiting.
But other options also have their disadvantages. White once had Medi-Cal but was booted off when re-enrolling her husband and has had trouble navigating public health coverage. The Mexico City native and legal permanent resident prefers Healthy SF to Covered California, which charged her $400 a month at one point.
“For some reason, when [her husband] was moved for Medicare, they dropped me instead,” White said. “We never could get me enrolled again. The health system is like a maze.”
Maria Misthos joined Healthy SF when she lost her job in 2008 and was assigned North East Medical Services as her medical care provider. As ACA rolled out, she switched to Medicaid, but spoke highly of the city option.
“I was on the program and I loved it,” Misthos said of Healthy SF. “It didn’t cost me anything. I found through NEMS it was very, very good.”
Misthos added that it took a lot of paperwork to get enrolled; the one year she forgot to renew and did not receive a letter to remind her, it took a week to get back on. But she found it was just like going to a regular doctor for basic care, such as mammograms.
Fernandez said Healthy SF has provided her with routine physicals and scans for her ovarian cysts, but she must pay out of pocket for dental or vision. Although she needs glasses, she hasn’t been to an eye doctor for three years since it costs $100 for each visit. This year, she decided to prioritize fixing her molars to the tune of $1,700 on a payment plan. Her children are eligible for Medi-Cal, but the cost of cavities and braces come out of her pocket.
DPH also instructed medical providers to cover coronavirus tests after the pandemic took hold.
That became an urgent need for Fernandez when the elderly woman she worked for as a caretaker contracted COVID-19 and died in August. While the pandemic exposed a high lack of primary care physicians among Latinos, Fernandez was immediately able to contact her clinic through Healthy SF to get tested, confirming within a few days it had spread to her and her younger daughter. And because Healthy SF coverage wasn’t tied to work, her coverage continues as she grapples with unemployment and still lacks a complete sense of smell.
The requirement to pay for vision and dental out of pocket remains a barrier for many.
Her husband has also since enrolled in Healthy SF, after many years when the family wasn’t aware he qualified.
“After all this that happened, my husband has Healthy SF,” Fernandez said of the coronavirus experience. “Nobody told me he qualified. I thought it was just for women and children.”
As San Francisco weathers the fiscal crisis stemming from the pandemic, DPH has not made any cuts to Healthy SF services, Kurniadi said.
But it’s not just about delegating resources — residents need to have better access to information on benefits, including updates like the renewal status and the potential impact of “public charge” policies, Contreras noted.
“We are seeing this community still left out,” Contreras said. “We may have the resources available but the transfer from resources to community, it’s still not there even with COVID. We’re definitely seeing a huge health disparity develop right in front of our eyes.”
At least some state legislators agree. Assemblymembers Joaquin Arambula, who represents Fresno, and David Chiu, who represents San Francisco, introduced a bill in December that would expand Medi-Cal coverage to all undocumented Californians.
But until the government finds a way to ensure everyone is covered for basic medical care, a need for Healthy SF will persist. Kurniadi said DPH has continued trying to get messaging out, train interested parties such as Martín-Baró organizers about the program, and reach people where they are in the meantime.
“What we would love to see is a day where everyone has coverage — true, full-scope coverage that has the things that are missing from our program,” Kurniadi said. “It would be great if we got to a point where our program wasn’t needed. But the program is committed to being around for those who don’t have other options.”
This article was produced as part of a data fellowship with USC Annenberg Center for Health Journalism. The Center’s engagement editor, Danielle Fox, contributed engagement support and Jacqueline Pinedo contributed reporting and translations.