Healthy San Francisco enrollees express high levels of satisfaction with city's health access program and survey shows signs of improved access to care

Challenges Remain as One Quarter of Enrollees Say They Delayed or Skipped Care or Medication Since Joining the Program

As states and cities struggle with the economic recession and possible fiscal pressure on public health care programs, a new Kaiser Family Foundation survey of enrollees in Healthy San Francisco (HSF), the city's health care access program for the uninsured, reports high rates of satisfaction and signs that the program has improved access to care for those uninsured residents who have enrolled.

In 2006, San Francisco created a unique health access program to provide access to affordable basic and ongoing health care services for its uninsured residents at participating clinics and hospitals. All uninsured city residents not eligible for other public coverage programs are eligible to enroll. As of August 2009, more than 45,000 people had enrolled in the program.

The report is based on a March 2009 independent survey conducted by Kaiser Family Foundation researchers to gauge the opinions and experiences of HSF's first wave of participants, the vast majority of whom have incomes below the federal poverty line. Participants report high levels of satisfaction (94% are at least somewhat satisfied with the program) and endorsement of HSF (92% would recommend to a friend and the same share think other cities should create similar programs).

The survey also reveals some reported improvements in access and costs for participants. Four in ten enrollees (41%) report improvements in how well their health needs are being met under HSF compared to before the program existed. More than four in ten enrollees (44%) report paying less for health care than before they joined the program, including about a third (32%) who say they are paying a lot less. On the other hand, fifteen percent say they are paying more now.

Comparisons with previous surveys also provide some indications that there may be improvements in access to care for uninsured residents who have enrolled in the program. The vast majority of enrollees (86%) say they have a place to go when they are sick or need health advice, a share that is substantially higher than the share of uninsured San Francisco residents who previously said they had a usual source of care before the program was created (51%, using 2003 and 2005 data combined(1)).

Challenges do remain for HSF, especially for certain groups of enrollees. About one in five of those in poor health or without a high school diploma report not understanding how HSF works and more than a third of Spanish speakers, those without a high-school diploma or in poor health don't understand what costs they are responsible for in the program. Additionally, about a quarter (26%) of all enrollees report delaying or skipping medical care or medicine since joining the program, and half of these respondents (13% of all enrollees) attribute these delays to the cost of care or a lack of insurance.

"Healthy San Francisco does not insure the uninsured, but it does represent a unique model of knitting together a group of clinics and some hospitals with a financing mechanism to provide access to care and that's a major achievement for any city, especially in such a bad economy," said Kaiser President and CEO Drew Altman.

Challenges Facing the Program

A key factor for the success of a new program is how informed the target population is about how the program works and what it actually provides. In the case of HSF, most people enrolled say they at least somewhat understand the program, but about one in five of those in fair or poor health (22%), those in fair or poor mental health (22%) and those with no high school diploma (21%) say they do not understand how the program works.

Further, almost three in ten (28%) HSF enrollees are confused about the costs they are personally responsible for paying. The share who say they don't understand what they must pay is even higher among Spanish speakers (41%), those without a high school diploma (36%), those in fair or poor physical or mental health (36% and 34%), and those with incomes below the federal poverty level (32%).

"Some of the educational challenges that Healthy San Francisco faces are typical in the initial stages of large scale health coverage programs," said Kaiser Vice President and Director of Public Opinion Survey Research Mollyann Brodie. "The survey shows that there are key groups of people like those in poor health and non-English speakers that could be better informed of how the program works and what it covers."

Other educational challenges facing HSF include:

• One in five enrollees (20%) report that they needed care they thought was covered, but then discovered it was not covered by the program--an experience more commonly reported by groups that are typically heavy users of health care services including those in fair or poor physical or mental health (26% and 29%) and those with chronic conditions (24%).
• Nearly four in ten enrollees falsely believe that one can receive care from the program at locations outside of San Francisco or say they don't know.
• Nearly three in ten enrollees are unsure whether they need to re-apply each year to remain in the program.

Recommendations for Program Improvements

When asked how HSF could be improved in an open-ended question, about four in ten (41%) program participants could not think of an improvement or were satisfied with the program as is. Among those that answered with a recommendation, the two most common answers were streamlining the appointment process (13%) and providing additional benefits, such as dental and vision care (14%). Other categories of recommendations of note include improving access to care and access to providers (10%), followed by improvements in customer service and communications (7%) changes related to policy and increasing public awareness (6%), lowering the overall cost to participants (4%), and improving the quality of care and facilities (4%).

Methodology

Researchers at the Kaiser Family Foundation designed the Survey of Healthy San Francisco Participants to gauge the early experiences and opinions of the first wave of enrollees in Healthy San Francisco. The survey was conducted with input from and the full cooperation of the San Francisco Department of Public Health; however, final survey design decisions and all reporting and analysis were performed independently by Kaiser Family Foundation researchers. You can view the full survey report online at http://www.kff.org/kaiserpolls/kaiserpolls082609nr.cfm.

The survey is based on a representative random sample of 1,026 participants who were enrolled in Healthy San Francisco as of October 31, 2008 and still enrolled as of March 1, 2009, in order to include those who were in the program for at least four months. The survey has a margin of sampling error of plus or minus 3 percentage points. Interviews were conducted in English, Spanish, and Cantonese, and efforts were made to ensure that the demographics of those interviewed closely matched those of the total Healthy San Francisco participant population.

(1) Source: KFF analysis of California Health Interview Survey.

The Kaiser Family Foundation is a non-profit private operating foundation, based in Menlo Park, California, dedicated to producing and communicating the best possible analysis and information on health issues.