SAN FRANCISCO
As Democratic presidential candidates unveil proposals for universal or near-universal health care for all Americans, San Franciscans are already signing up for a new program that guarantees free or sliding-scale medical care to all uninsured adults. The program provides a network of care to city residents, regardless of pre-existing medical conditions, immigration status or ability to pay.

For Judy Rees, a 45-year-old part-time home health aide, the program, dubbed Healthy San Francisco, will coordinate treatment for her slipped discs, borderline diabetes, and anxiety. "I've never had insurance," she said yesterday as she read a Healthy San Francisco flyer in the waiting room at Glide Health Services, a clinic in the impoverished Tenderloin district. "I'd never go to the doctor unless I was deadly sick."

"You never know what's going to happen," said Frederic Tarmis, 38, an uninsured bartender in the Glide waiting room who said he was anxious to sign up for the program. "I try not to think about it."

Bill Henry, 63, a part-time gardener, said he'd been navigating the city's free health clinics and San Francisco General Hospital for years and wasn't sure he needed the plan. Then he added, "Once I went to General and didn't know where to ask and I ended up getting bills."

The plan, which began in pilot form in July and expanded citywide this week, is the first attempt by a U.S. city to tackle the health care crisis on its own, albeit with the assistance of state and federal funds. Unlike other universal health care plans being proposed, Healthy San Francisco is not insurance, because the health coverage doesn't travel with the individual. Care is only provided and paid for at clinics and hospitals in the city.

"What we're seeing here is the absence of real action at the federal level," said Ken Jacobs, chair of the University of California, Berkeley Center for Labor Research and Education. "It certainly sends the message that this is possible."

At the root of the program is the concept that each patient will have a "medical home" at a particular city clinic, so that treatment and referrals can be coordinated. The intention is to shift medical treatment for the uninsured from dire trips to the emergency room to ongoing, preventative care. "It's challenging to get a colonoscopy screening and the waiting lists for mammography are long," said Dr. David Bangsberg, a researcher at the HIV program at San Francisco General, who said the new program would change those problems.

The other key is the white Healthy San Francisco medical identification card, which features a picture of a heart and the San Francisco skyline. The security of having a medical card is "gigantic," said Patricia Dennehy, divisional director of Glide Health Services, who said the card gives patients information before emergencies about how much they'll owe. In one instance, a colon cancer patient at the clinic refused to go to General hospital for surgery, regardless of assurances from the staff that he could receive low-cost care, Dennehy said. "He had a small bank account," she added. "He said, 'If I go, they'll find that money.' " .

The card may also make the program more appealing to middle class patients. "It's not a hand-out, it's not a free clinic," she said. "It's a plan."

By targeting the city's estimated 82,000 uninsured adults between ages 18 and 64, instead of the entire population of 750,000, the program is able to leverage the existing infrastructure of 22 city and community-based health clinics and the resources of San Francisco General, a teaching hospital affiliated with the University of California, San Francisco. More than 1,300 people have enrolled in the program to date.

As for replicating the program elsewhere, what's needed is an established public health system, said Stephen Shortell, dean of the School of Public Health at the University of California, Berkeley. "Chicago is a good example of another city with a strong health department and an infrastructure of city clinics," he said. "It's one of the cities that could do this."

San Francisco already has a Cook County-style health care system for the poor—with a big public hospital, and clinics for the indigent. But Chicago's doesn't have anything like San Francisco's attempt to enact universal health care for all its citizens. In Chicago, poor people can go to the Cook County Health System for care—those who are uninsured often stand in line at county clinics or the ER—but there is no guarantee of medical coverage, except in life-threatening emergencies.

Even California Gov. Arnold Schwarzenegger's introduction of a statewide health care plan was "clearly" spurred by Mayor Gavin Newsom's health initiative in San Francisco, said Jacobs.

The city currently spends about $117 million to care for about 50,000 of the uninsured, the majority of whom are working men under age 40. Healthy San Francisco estimates it will cost $200 million to fund the program. To defray some of the difference, the city received a $73 million grant spread over 3 years. The remainder is expected to be paid for by contributions from employers. The Golden Gate Restaurant Association has filed a lawsuit to challenging the contributions; a judge has scheduled a hearing for November.

Until November, enrollment is limited to adults with income at or below the federal poverty level of $10,210 for a single person and $20,650 for a family of four, who pay no fees. After November, enrollment is open to individuals at all income levels with quarterly fees ranging from $60 to $675, which is the amount for incomes at 500 percent of the poverty level, or $51,050 for an individual or $103,250 for a family of four. Co-payments range from $10 to $20 per visit to a clinic and from $200 to $350 for a hospital stay.