In June 2006, San Francisco Mayor Gavin Newsom unveiled a plan to provide comprehensive health care for all San Francisco residents, including the city's 82,000 uninsured.

San Francisco's city council approved a version of the plan that August, and it is set to be implemented in phases beginning in July 2007.

"We have created a plan that will allow for every San Franciscan to have access to ongoing primary and preventive health care," Newsom said in a press release.

The San Francisco Health Care Security Ordinance, the United States' first city-level universal health plan, combines the mayor's Health Access Program, or HAP, and city Supervisor Tommy Ammiano's Worker Health Care Security Ordinance, which mandates that employers, depending on the size of their workforce, spend a fixed amount on employee health care.

The HAP offers health care access, not insurance, to any uninsured resident of San Francisco, legal or illegal, whose income falls below 500 percent of the federal poverty level and who does not qualify for federal insurance programs such as Medicaid.

The plan will cover most health care expenses incurred within the city limits, including prescriptions, primary care physician visits, and mental health care. It will not cover any expenses outside of the city or dental or vision care.

Newsom said at a June 2006 press conference that the plan could slow rising health costs by encouraging primary and preventative care.

"When [the uninsured] get sick now, they go to the emergency room or urgent care," Mitch Katz, the director of San Francisco Public Health Department, told the San Francisco Chronicle in July 2006. "One of the things we want to create is a medical home where people can go."

Who will foot the bill?
The plan will cost approximately $200 million, and though some individuals receiving the coverage will be required to pay annual premiums of up to $150, depending on income level, to help fund the program, those involved in the planning process anticipate funding from a variety of sources.

The city and county will provide about $104 million and individuals' premiums and co-payments will add around $60 million, but a significant amount -- between $30 million and $40 million -- is expected to come from local employers who will be required to spend a minimum amount on health care.

Businesses with between 20 and 99 employees will be required to spend $1.06 per hour for each worker, while businesses larger than 100 employees will have to spend $1.60 per hour.

The employer expenditure requirement gives employers a choice of how they spend the money on health care. Although they aren't required to purchase the HAP for their employees, city officials are hoping that it will provide a low-cost, high incentive option.

But city businesses have balked at the ordinance's employer mandate. In November 2006, the Golden Gate Restaurant Association (GGRA), which includes more than 800 of the city's restaurants, filed a lawsuit claiming the mandate violates the federal Employee Retirement Income Security Act, or ERISA, which blocks state or city governments from implementing employee benefit programs.

"The new system would be putting a system that doesn't work on the back of the employer," said Kevin Westlye, the association's executive director.

The city filed a response in late December and the judge has reviewed both parties' documents, according to HAP Director Brigham, but a hearing has not been set.

In March 2007, Westlye and the GGRA threatened to shut down their restaurants for a day to protest the increased costs of operating a business.

Despite the lawsuit and protests, the program is still set to begin July 1 for residents who currently receive some city-funded medical care.

"In terms of the health access program, we are continuing to do the planning," Brigham said. "July 1 is the date."

Restaurants and other businesses will not be required to contribute money towards employee health care until January 1st, 2008.

Keys to a successful program
Funding aside, other issues, such as outreach and timely access to care, have to be addressed in order to implement the program successfully, experts say.

"The current safety net system [which provides care to the uninsured] has bad waits," said Dr. Mark Smith, who works with AIDS patients at San Francisco General Hospital, the program's proposed hub. "If you're trying to refer someone to specialty care, you've got waits of weeks or months."

But Stephen Shortell, dean of the University of California-Berkeley's School of Public Health, said that difficulties with outreach may keep demand on the program down initially.

"Unless they invest in some outreach workers and information where these uninsured people are, maybe that the demand the first year or so will be lower than they expect, which will be good from a cost standpoint," he said. "I think they're going to have to do quite a bit of outreach to get people to use this new system and to explain it well, because [the uninsured] are used to doing what they do now: getting no care until it's needed and then going to the ER."

Another key to the program's success is developing information systems technology to track patients.

"They recognize one of the major problems they're going to have in implementing [the program] is the need for information systems technology," said Shortell. "It would be a disaster if these people are not getting the care they need or not keeping track of their records. This is one of the reasons that they're talking about phasing in [the program] slowly."

Brigham agreed that the plan will need to be implemented gradually.

"We've been very clear from the beginning that this is a phased-in approach," she said "You don't from day one enroll 82,000 potential people in a program -- that's not going to happen."

The city is considering two methods for gradual implementation. One is a clinic-by-clinic approach that would transition the users of the city's current public health care clinics into the HAP one at a time. The other is to use the monthly eligibility recertification process that people seeking to use the city's safety net plan must undergo and transfer people into the HAP program instead of the existing system.

"On a monthly basis, individuals are recertified for their eligibility [for free care]. One of the options might be, well if we know that, on a monthly basis, 2,000 to 2,500 people are recertified, that perhaps should be the approach and the strategy for enrolling them in the HAP," she said.

The HAP Advisory Committee will decide which method to use in March.

-- By Jonathan Brand, Online NewsHour