UA CoveringSF 2 23 06

Covering San Francisco: 

Covering San Francisco Private and public coverage and the gaps Jean S. Fraser, CEO, San Francisco Health Plan Presented at Universal Healthcare Council February 23, 2006

Today, we’ll try to answer three questions.: 

Today, we’ll try to answer three questions. Who has insurance, whether through private or public coverage, and who doesn’t? What happens to people who have no coverage and they need care? What do we know about full-time working uninsured San Franciscans?

The U.S. health care system is based on employers paying for medical insurance.: 

The U.S. health care system is based on employers paying for medical insurance. This is a historical artifact, not a conscious policy choice. There is no requirement that employers provide care; reliability of coverage changes with market conditions. The incremental costs of health insurance for low-wage workers is high, so those most likely to be uninsured are least able to pay for their own care.

Most people have insurance through employers paying for medical insurance.: 

Most people have insurance through employers paying for medical insurance. 85% of San Franciscans have insurance, primarily through an employer or as a dependent. 15% of San Franciscans, or 82,000 people, are uninsured at any one time. Many more of us are uninsured at one or more times in our lives.

Slide5: 

300+% FPL 200% FPL 100% FPL Federal Poverty Level Employer/Private Coverage Unemployed and uninsured Employed, <10 employees, and uninsured Employed, 10+ employees, and uninsured Coverage Status of San Francisco Adults Uninsured Adults

Slide6: 

300+% FPL 200% FPL 100% FPL Federal Poverty Level Accepted health benefits Eligible, but did not accept Not eligible for benefits offered Employer didn’t offer benefits = 24,000 uninsured = 16,000 uninsured = 14,000 uninsured = 38,000 uninsured Most uninsured working people are not offered or eligible for health benefits.

Government tries to fill in the gaps in employer system.: 

Government tries to fill in the gaps in employer system. Government programs created piece by piece at different times by different people with no grand plan. Government has used different ways of filling in gaps – from paying for insurance to paying for specific types of care to mandating care without payment. Result is patchwork that confuses everyone, is inefficient, and has many holes.

Government tries to fill the gaps…: 

Government tries to fill the gaps… The U.S. has universal health insurance for the elderly. San Francisco has universal insurance for children aged 0-18. Between 19 to 65 years, there is no subsidized insurance unless you: Are very poor and disabled, or Are very poor and have minor children. There is no subsidized insurance for “regular” 19 to 65 year-olds. By paying for insurance for poor kids, parents and disabled people.

Slide9: 

Government Covers Kids, Elderly, and a Few Poor *There is some coverage for people with breast, cervical, or prostate cancer, for TB, dialysis, family planning services. There is also a very small State-run program for people with pre-existing conditions.

Government tries to fill the gaps…: 

Government tries to fill the gaps… EMTALA: All hospitals with emergency departments must treat patients until they are stabilized without demanding payment prior to treatment; then may transfer to hospital willing to accept patient. People still get bills. By mandating emergency departments to give treatment before being paid

Government tries to fill the gaps…: 

Government tries to fill the gaps… By giving money to some providers to provide treatment. Federal and State funds go to hospitals that treat many low-income people (SFGH, St. Luke’s). Federal and State funds go to outpatient clinics that treat many low-income people (e.g. DPH health centers, community clinics).

Government tries to fill the gaps…: 

Government tries to fill the gaps… Eligibility and benefits not defined in law. San Francisco is one of most generous in eligibility and in benefits. Care is provided thru City-owned institutions – SFGH and health centers. DPH bills patients using a sliding scale of fees, though in many cases they still get large bills. By mandating that California counties provide treatment.

Providers also try to fill the gaps…: 

Providers also try to fill the gaps… Other than at community clinics, care is provided primarily through EDs, though not exclusively. Eligibility and charges not uniform across providers. By providing charity or reduced fee care.

In truth, San Franciscans have universal access to care: 

In truth, San Franciscans have universal access to care We should be very proud that no one is turned away from SFGH, health centers, or hospital EDs due to income or insurance status BUT ….

But people don’t know about it and the programs have some problems.: 

But people don’t know about it and the programs have some problems. Sliding scale and charity care programs are not well-known. There is no assurance of the timeliness of care, except via EDs. There is no certainty of costs to patient, and patients often get big bills. There is no clear route for follow-up care outside of EDs. Eligibility screening is not coordinated or done everywhere.

What if we focused on uninsured, full-time San Franciscans?: 

What if we focused on uninsured, full-time San Franciscans? What do we know about full-time working uninsured San Franciscans?

82,000 San Franciscans are uninsured: 

82,000 San Franciscans are uninsured

46,000 San Franciscans are employed and uninsured : 

46,000 San Franciscans are employed and uninsured

38,000 San Franciscans work more than 20 hrs per week and are uninsured: 

38,000 San Franciscans work more than 20 hrs per week and are uninsured

16,000 San Franciscans are in companies of 10+ employees, work 20+ hrs/week, and are uninsured: 

16,000 San Franciscans are in companies of 10+ employees, work 20+ hrs/week, and are uninsured

The answers to the three questions.: 

The answers to the three questions. Who has insurance, whether through private or public coverage, and who doesn’t? Most people have private coverage, with kids, the elderly, and poor disabled or parents having government coverage. 82,000 San Francisco residents have no insurance. What happens to people who have no coverage and they need care? They can get care, but many don’t know, and the timeliness and the cost to them is uncertain. What do we know about full-time working uninsured San Franciscans? 16,000 San Franciscans are uninsured, work 20+ hrs/week for firms with 10+ employees.