A few months back, I found myself in the emergency room at San Francisco General Hospital, doubled over in pain but strangely euphoric. The morphine had something to do with it, but mostly it was peace of mind. With the country in a tizzy about healthcare reform, rationing, and a government-funded “public option,” here I was—technically uninsured, yet in the hands of some of the best doctors and nurses in the Bay Area (or anywhere). If this is what socialized medicine looks like, I thought, bring it on.
That might sound strange coming from someone like me, the daughter of an anesthesiologist at a world-class hospital, who grew up getting the best private healthcare money could buy. Even after I became a freelance journalist, top-notch medical care and insurance were among the things I never thought I’d have to go without. Late last year, though, I got a rude awakening. At 32, I was in excellent health, but like multitudes of other Americans who have used preventative medicine—even antidepressants or acne cream—to stay that way, I was deemed too great a liability to the insurance industry’s bottom line. The only insurance I could find was a “catastrophic” plan with sky-high premiums, a $5,000 deductible, and no prescription coverage—doable, but only for so long. Then I’d be left without insurance or savings, and with book advances and magazine checks more sporadic than ever, I needed my financial cushion more than I needed an HMO.
Welcome to the great conundrum facing American workers as we struggle to stay afloat in the most disruptive economic times in 70 years. To the millions of people who have lost their jobs and health benefits, add millions of others who are toiling as independent contractors, whether they want to or not, with plenty of entrepreneurial and artistic freedom but minimal safety nets. This is what the middle class looks like now—you don’t always work for other people; you work for yourself at home or in a café, or you work a series of part-time jobs and feel grateful to have them. The “gig economy,” as some call it, is the future—though in the Bay Area, where so many of the people you meet are self-employed and uninsured, with packed schedules and positive cashflow, the future is already here. The old, employer-based model of health insurance doesn’t serve the needs of this 21st-century workforce—not that it functioned particularly well in the 20th century, either. That’s why the machinations in Washington have been so urgent and ugly. But as much as the changing middle class (and everyone else) needs a whole new approach to insurance, true reform is so agonizing that it seems hard to believe it will ever really happen—or that, if it does, it will be better than what we already have.
Meanwhile, lucky for me, there’s Healthy San Francisco (HSF), the city’s two-year-old health-access plan, which has recently become available to middle-class residents and which I joined just a few weeks before my trip to the emergency room. The source of my misery turned out to be only a kidney stone, easily curable by drinking lots and lots of water. But to figure this out, I had to undergo a myriad of expensive tests; the MRI alone cost upward of $3,500. A month or two earlier, I would have been frantic at the thought of pouring all that money down the drain to diagnose what turned out to be a relatively mundane ailment. But with Healthy San Francisco, instead of worrying about maxing out my credit cards, all I had to do was lie back and let the doctors and nurses—and the morphine—take over.
Whatever happens with healthcare reform on Capitol Hill, here in our little fog-shrouded bubble, we can all rest (relatively) easy: Some of the smartest, most enterprising health-policy wonks on the planet have pieced together a program that aims to provide healthcare access to virtually every uninsured resident aged 18 to 64, regardless of employment, citizenship, or preexisting conditions—some 63,000 people in all, or 8 percent of the city’s population. Healthy San Francisco isn’t insurance—it’s a system of providers that uses the city’s superb healthcare infrastructure: neighborhood clinics, community hospitals, public health centers, and the state-of-the-art resources of UCSF. It doesn’t replace other government programs, like Medicare or Medi-Cal; it just ensures that people who don’t qualify for them don’t fall through the cracks. To enroll, all you do is show proof of residency and income: The cap is now $54,150, though officials hope to open HSF to all income levels by the end of 2010. Other than a requirement that new participants be uninsured for three months prior to joining the program, there isn’t even a waiting period.
HSF is, hands down, one of the best healthcare bargains anywhere. For individuals earning less than $10,830 annually, the program is free. For everyone else, basic enrollment is $20 to $150 per month (versus $409 for the average California insurance premium), with rock-bottom copayments: $10 for primary care visits, $200 for hospital admissions, and $5 to $25 for medications. The fees are so low, in fact, that at times I’ve felt like I’m duping the system. The program’s cost for fiscal 2008–2009 was $126 million, of which about $3 million came from participants (most of the rest was from employers and local and federal governments). I had expected to pay around $100 a month—an amount I could easily afford. But according to the program’s calculations, which frequently underestimate earnings for people who are self-employed, I actually fell below the federal poverty level and wouldn’t have to pay a dime. My total cost for my kidney-stone ordeal was cab fare to the emergency room.
Instead of feeling jubilant, though, I worried that the folks signing me up for HSF would look at my expensive bike-messenger bag (a freebie), vintage leather boots (a Salvation Army score), and dangly earrings (a present from my sister) and assume that I was a poor little rich girl, a trust-fund fraud. But HSF sees plenty of people who are not so poor that they meet federal standards for Medicaid, yet not so flush that they can afford outrageously priced insurance premiums and still live in San Francisco. The woman helping me didn’t blink an eye at my clothes or my application—if anything, she seemed eager to get me into the program no matter what. She even handed me a card for deep discounts on birth control, and while I couldn’t help wondering at the rationale behind this unexpected perk (“Let’s keep the welfare women from getting knocked up”?), I had to admit: That card was going to come in handy.
For anyone used to getting the shaft from insurance companies, HSF’s welcoming stance is a shock to the system. Robert Arnold, a 43-year-old documentary filmmaker who could easily pass for 30, lives the quintessential Peter Pan/San Francisco lifestyle, complete with two roommates and no real assets. Years ago, he traded in his $80,000-a-year Macromedia job in favor of more creative work. This past September, he swapped his private insurance for public care. As a strong backer of healthcare reform with a public option, he felt a stab of pain every time he wrote a check to Blue Shield, which he knew was funding anti-reform lobbyists. As his age crept past 40 and his monthly premiums nearly doubled, his anger festered. “Paying into the health insurance company’s corporate profits is just not cool with me,” he says.
What struck Arnold most about HSF was that instead of trying to disqualify him—often the knee-jerk reaction of private insurers—the program did everything it could to make it easier for him to enroll. “I guess it makes sense, since they are focused on providing a service instead of making a profit,” he says, “but it just felt so different.” In contrast, he had to make four calls to Blue Shield, getting lost in its automatic phone system each time, before he found a live person who could cancel his plan.
When you sign up for HSF, you choose a “medical home” from a list of 30 providers around the city, including community clinics, Department of Public Health centers, and hospitals. This is where you receive the bulk of your primary care and where the staff coordinate your appointments with specialists (including plenty of UCSF hotshots), lab tests, and surgeries.
To find my “home,” I did exactly what I do when I’m looking for a hairstylist or a restaurant: I turned to Yelp. Some of the best ratings were for a place completely off my radar: Lyon-Martin Health Services, in Hayes Valley, which describes itself as “the only freestanding community clinic in California, with a specific emphasis on lesbian/bisexual women and transgender healthcare.” Transgender medicine, it turns out, involves all kinds of cutting-edge issues that attract high-caliber doctors and nurses focusing on women’s health. The Yelp reviews were filled with five-star ratings and exclamation points: “By far the BEST annual gyno visit I’ve ever had.” “This place is one of the main reasons I live in San Francisco.” “I’m still basking in the warm, fuzzy feeling from the caring, courteous service I got there yesterday.” “GO LYON-MARTIN! I love you.”
I figured that the clinic’s queer focus would mean a staff willing to answer any question without being judgmental—a huge plus, even if you’re straight. On my first visit, the receptionist was a hot young tattooed lesbian who probably has a major fan base at the Mission’s Lexington Club. The nurse practitioner was attentive, thorough, and easy to talk to. It felt like any other private clinic, except for the pamphlets discussing sex-change operations and the numerous options for describing my sexual and pronoun preferences: Straight, gay, bisexual, asexual? He, she, ze, hir?
The most burdensome part of my care isn’t even the clinic’s fault. Like most HSF participants, I have to get my medications at San Francisco General’s pharmacy, which processes 10,000 HSF prescriptions a month on top of its normal load. Signs explaining the pharmacy’s procedures are confusing or nonexistent. Orders for refills must be placed exactly two days before a prescription is due to run out. But there are plenty of tricks to make the experience more pleasant, and I find the sense of camaraderie with the other people in line oddly comforting. I like the idea that all of us trying to make a go of it in San Francisco—whether we’re freelancers, artists, or unemployed single mothers—are in this healthcare experiment together. Having to wait an hour for my pills is a price I’m willing to pay. Plus, my freelance office consists of a laptop, a BlackBerry, and a stack of manuscripts. I can proofread my book galleys or catch up on email while I wait in line. If I need some coffee, there’s a cart nearby. For an independent, high-tech professional on the go, it works.
In a recent Kaiser Family Foundation survey, a whopping 94 percent of users expressed satisfaction with HSF, while almost as many said they planned to continue with the program and would recommend it to friends. Those numbers are as high as you’ll find for medical care anywhere. Even doctors—some of the loudest and most influential critics of healthcare reform in the past—have been impressed by the results so far, my father included. When I fell ill, he was nervous about my being treated in a public hospital, so he got on the phone to my doctors at S.F. General and grilled them. He quickly concluded that my care was first-rate—as good as what I’d receive at an elite private institution.
In fact, I’ve been struck by the number of people who insist that HSF offers better care than their private insurance did. These are not people foisted on me by some eager-to-impress PR machine. They are just normal folks, like Margaret Cooley, a 55-year-old writer whose husband used to work at Apple. When she tripped and fractured her wrist during a visit to Illinois two years ago, a doctor recommended implanting a device to help her maintain full use of her hand, and Blue Cross okayed the surgery. But a few weeks later, medical bills started filling her mailbox, eventually totaling $14,000. The procedure, it turned out, was only covered if it was done at a hospital. “I contested it,” Cooley says, “but Blue Cross said it wasn’t their fault that I didn’t understand my coverage.”
Dropping her private plan was a no-brainer: As she says, “I felt it was pretty much worthless anyway.” A year later, when Cooley felt an odd sensation in her wrist, HSF sent her to a UCSF orthopedist who happened to be studying the long-term effects of the type of device in her arm. Cooley’s implant was on the verge of causing permanent damage, a possibility the Illinois doctor had neglected to mention; HSF sent her for surgery right away. “Can you imagine if I had gone around with that device in my wrist and no one even bothered to tell me, because they don’t want me to use my health insurance again?” she asks. “I just feel so lucky.”
Sharon Donnelly, 50, feels even more fortunate. She has hydrocephalus, a condition in which fluid develops in her brain. She has a shunt in her head that requires continual monitoring and, every few years, replacement via surgery. That condition, along with high blood pressure and high cholesterol, makes it nearly impossible to find insurance on her own. Yet last year, she quit her library assistant job, giving up her private coverage and enrolling in HSF soon after. As a kid, she went to top specialists affiliated with Columbia and Harvard. Her HSF care, she says, is just as good.
What makes Donnelly’s story amazing, though, is that her HSF team detected an entirely different—and potentially fatal—condition that had been overlooked by her Pacific Heights general practitioner when she was covered by private insurance. Like the staff at many community clinics, the nurses at her “home,” Lyon-Martin, were accustomed to patients who rarely seek medical attention—so they were trained to look for every possible ailment. During Donnelly’s first physical, a nurse noticed that her thyroid was asymmetrical and immediately ordered a CT scan and biopsy. The tests turned up thyroid cancer. Now, five months later, Donnelly is undergoing treatment, and if she ever gets another job with insurance, she’ll fight to keep her HSF docs. As she often says, “Healthy San Francisco saved my life.”
For all the benefits of HSF, though, two of the most common middle-class reactions I’ve encountered are squeamishness and anxiety. When Robert Arnold, the indie filmmaker, decided to drop Blue Shield for HSF, he was taken aback by how conflicted he felt. “It was like I was downwardly mobile or something,” he says. “I thought, ‘Here I am, in my 40s, using free health services. Should I try to be more professional?’”
That kind of ambivalence highlights one of the surprising dilemmas facing the middle and working classes—in San Francisco and in the country as a whole—as healthcare reformers try to fix our broken system. Millions of middle-class Americans have no health insurance, and it isn’t just those who have lost their jobs: Nearly two-thirds of uninsured Americans work. In California, 15 percent of uninsured people earn more than $32,500; in notoriously expensive San Francisco, that figure is a sobering 30 percent. Yet though middle-class people are desperately in need of reform, our discomfort with publicly funded care may be the biggest impediment to achieving it.
It’s hard to put numbers on this problem as it relates to HSF, because so few people realize they are eligible to participate. When the program launched in 2007, it was available only to individuals who lived at or below the poverty line. HSF raised its annual income cap to the current $54,150 last winter. But of the 19,000 people newly qualified to enroll, only about 500—or about 2 percent—had done so as of last month. In part, that’s because city officials decided not to waste limited funds on a costly advertising campaign. Organizers also didn’t want to risk crashing the fledgling system by taking on more patients than its infrastructure could handle. But even some people who know about the program and could really use it are reluctant or refuse to do so.
Ellen Shershow Peña, for example, has been dragging her feet for months, though she swears she plans to sign up for HSF soon. Her artistic career had been stagnating, so last summer, at the age of 37, she quit her job at the San Francisco Arts Commission to start her own freelance photography business. She figured COBRA—temporary coverage that insurers are required to offer when someone leaves a job—would buy time to shop for an affordable plan for her and her husband. But the monthly premium was more than their rent. HSF soon emerged as their only viable healthcare option—a fact that makes her none too happy. “I did all the things I was supposed to: I went to a top college, a top grad school, and I am trying to further my career,” Shershow Peña says. “And now I’m being told to go to a free clinic? This is what my option is? I don’t want to sound whiny, but part of me is mad.”
“I believed the story that if you worked hard, you would reap the rewards,” she adds. “But maybe I was wrong.”
Of course, plenty of middle-class Americans get publicly funded healthcare—military families, veterans, seniors on Medicare. But to a lot of people, having to rely on a system like San Francisco’s feels like being on the dole. Sandra R. Hernandez—CEO of the San Francisco Foundation, the city’s onetime health director, and cochair of the committee that helped plan HSF—has seen this dynamic in the Healthy Families Program, a precursor to Healthy San Francisco, which offers kids 18 and under comprehensive healthcare. It turns out that many parents who qualified for free care under Medi-Cal actually would have preferred Healthy Families, with its nominal fees, because the payments would have made the program feel less like a handout. Hernandez says that’s an important lesson to be learned for healthcare reform. “The stigma may deter people, even those who might be eligible,” she says. “The nationwide assumption is that if the cost of a public plan is lower, people will sign up. But no one is factoring in the question of whether people will want to enroll.”
The widespread belief is that you get what you pay for—and that private insurance is therefore always superior. That seems to be the attitude of 57-year-old Anne Walzer, who lost her Kaiser insurance owing to a fluke involving an administrative error, a missed deadline, and a preexisting condition. HSF “was really a last resort,” she says, adding, tongue in cheek, that she would have preferred getting married for insurance before stooping that low.
Walzer’s previous experience with free public clinics only increased her reluctance. She had used them in her bohemian 20s, but now, as a successful freelance art director working for Storefront Political Media and Marin Magazine, she felt she deserved better. At one point during the two-plus years when she was uninsured and fighting with Kaiser to have her coverage reinstated, she cut herself with a rusty X-Acto knife and went to S.F. General’s urgent-care clinic for a tetanus shot. The waiting room was hot, crowded, and unventilated (“and women my age are particularly bothered by hot environments,” she laughs), with cartoons blaring on an overhead TV. When she fled to a quiet hallway, a security guard sent her back to wait with the hordes, people who, she says, “seemed really poor and sick, others homeless or crazy, and some just in really bad shape.” The breaking point came when two men who had been coughing next to her were hurried into a room with an “Isolation” sign.
Walzer was so resistant to HSF that she jumped at the chance to rejoin Kaiser through the state-run Major Risk Medical Insurance Program, which provides healthcare coverage to people with preexisting conditions. Never mind that her new plan carries a $10,000 annual premium and that, if she’d enrolled in HSF, where Kaiser has recently become one of the providers serving as an HSF medical home, she’d be paying a maximum of $1,800 a year. Walzer never wants to set foot in a place like the S.F. General waiting room again. “‘I have hit bottom,’ ” she recalls thinking. “‘I’m a middle-class person in a poor-people ghetto.’ It was the lowest I have ever sunk. I felt like a total failure in life.”
For people running or working at small businesses, which in San Francisco often means restaurants, HSF has significant downsides beyond the noise and the crowds. Of the program’s $126 million cost last year, some $14 million was funded by the city’s “play or pay” employer mandate. Businesses with 20 or more employees must contribute $1.31 to $1.96 per worker per hour toward some form of healthcare: either private insurance, a flexible spending account that sets aside money for healthcare needs, or the city option, including HSF. (Smaller businesses are exempt.) The city’s restaurateurs, who supply many of the part-time jobs that make it possible for creative types to write their novels or make their movies, have been up in arms, claiming that they can’t afford insurance and that they shouldn’t have to finance a program that their employees—who often live outside the city or share the middle-class wariness toward public care—may never use. As a result, some bosses play down the program and offer misinformation, which discourages their staff from signing up—or so some workers say.
A major drawback for people who do enroll: The program only covers you when you’re in the city. If you get hit by a bus in Berkeley or break a leg in Tahoe, you’re on your own. (“Healthy San Francisco is not insurance,” the HSF website warns. “If you have insurance, do not drop it. Insurance is always a better choice.”)
And HSF doesn’t just cut you off when you’re on vacation or commuting. Because the program is technically not insurance, enrollees are, well, technically uninsured. This creates a gap in coverage that gives private insurers another excuse to refuse you a policy should you apply on your own down the line. What’s more, every time you use HSF, you risk racking up another preexisting condition that could present an additional roadblock to getting private coverage. If I ever move, or if the city runs out of money and decides to abandon the program, or if the U.S. Supreme Court rules that the employer mandate violates federal law and that HSF must be drastically reworked or shut down—and President Obama and Congress don’t come up with an adequate replacement—I will be pretty much screwed. In this healthcare experiment, as in many other ways, San Francisco is so far ahead of the curve that we run the risk of being cut off from the rest of the country by our own cleverness and good intentions.
For all these reasons, I can see why Anne Walzer is willing to pay an extra $8,000 or more a year for the security of real insurance, especially considering how much she commutes and travels. (Not that Walzer’s high premiums leave her much money for airline tickets these days—an irony she freely acknowledges.) Moreover, Walzer has assets, including a Noe Valley condo, that she might lose if she were to be involved in a costly out-of-town accident. For her, the stakes of being uninsured are too high. But most HSF enrollees don’t have the same alternatives. For them, and for me, HSF is worth the risk and the hassle. Besides, as Sharon Donnelly puts it, “I could think of worse places to be stuck than San Francisco.” One thing you won’t hear anyone talk about—other than Gavin Newsom, when he was running for governor—is HSF as a model for healthcare reform at the national level. Essentially, what San Francisco has created is a variation on a single-payer system, beloved by starry-eyed progressives but not vote-counting pragmatists. “As the federal debate shows, our country is very far from considering a national health system,” says Mitch Katz, the city’s public health chief.
HSF wouldn’t even work in a lot of local jurisdictions. Unlike San Francisco, most places don’t have an extensive public health system upon which to build. Big cities or metropolitan areas might have the existing infrastructure and social need to create their own version of the program—Howard County, Maryland, for example, launched Healthy Howard in late 2008—but very rural communities in less populous states probably would not.
Politically, too, this place is unique. In San Francisco, representatives from every major stakeholder group were willing to make the compromises necessary to create universal access to healthcare. This stands in stark contrast to the atmosphere in Washington, where partisan wrangling and lobbyists’ exploitation of middle-class fears have made every step in the process an excruciating exercise in democratic sausage-making.
What Healthy San Francisco might be, though, is a role model for other cities if healthcare reform fails; or if the plan that comes out of Capitol Hill is so feeble that many people remain uninsured; or if reform takes so long to implement that localities need a stop-gap program to tide them over. (For example, even the most liberal reform plans are unlikely to cover illegal immigrants, who are eligible for HSF.) On the other hand, if reform is as sweeping as most San Franciscans hope—preventing insurance companies from rejecting people with preexisting conditions or gaps in coverage, or from pricing people completely out of the market—HSF would likely become obsolete for most middle-class residents. We should be so lucky.
Meanwhile, maybe HSF’s most important function, beyond the obvious saving of limbs and lives, is saving the way we middle-class San Franciscans live our lives—and showing Congress and middle-class people everywhere that publicly funded healthcare can work for them as well. In New York, the saying goes, “If you can make it here, you can make it anywhere.” With Healthy San Francisco, our city’s saying could be “If you can’t make it anywhere else, you can make it here.” You can be an artist or a writer or an entrepreneur without fear of falling sick; you can fall sick without fear of losing everything. You can lose your job and stick around to reinvent yourself for a new economy. You can be a middle-class person and still have dreams.
Justine Sharrock’s first book, Tortured, on soldier abuse of detainees in Iraq and Guantánamo, is due out in June 2010.