California: San Francisco Adapts for Health Reform

Health care reform may place unsustainable pressure on some safety-net systems created for the uninsured and low-income persons on Medicaid, according to Dr. Mitch Katz, San Francisco's director of health.

"Overall, I think health reform is good for people who are HIV-positive because, if they are low-income, it is going to make them eligible for Medicaid, regardless of their health status," Katz said. Medicaid patients with HIV can begin treatment much earlier, rather than when they progress to AIDS, he noted.

However, if enough Americans opt for private sector health providers, safety-net programs, particularly in rural areas, may be unable to cut costs fast enough or access resources to support infrastructure improvements, Katz said. Such an exodus would leave safety-net programs largely serving "only those people who are not eligible for health reform, by and large the undocumented."

The Healthy San Francisco program covers 53,000 uninsured people, and all are required to choose a medical "home." About 55 percent of program patients choose facilities operated by the city Department of Public Health (DPH), and 45 percent choose community clinics.

Safety-net providers can offer services that private providers and small group practices may not - such as language capabilities, links with other social services, and assistance with childcare and transportation, Katz noted. DPH's web-based application also identifies clients and their family members who are eligible for other public benefits.

The city's HIV programs provide "some of the best models" for delivering the best and most cost-effective care, and they ensure patients are linked with pharmacists, Katz said. "Often pharmacists are better than doctors on drug side effects, when to take medications," he said.

"The question to me, is, how to make sure that safety-net systems thrive under health reform," Katz said.

Katz earlier enumerated his concerns in a commentary, "Future of the Safety-Net Under Health Reform," published in the Journal of the American Medical Association (2010;304(6):679-680).

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