San Francisco’s health coverage program has been a lifeline – but it doesn’t reach many who need it

In early March of 2020, my project partner and I set out to do one final outreach session at Zuckerberg San Francisco General Hospital, where a majority of patients went for care under the program at the center of my Center for Health Journalism data fellowship.

We were feeling good about the number of patient surveys we had already collected with CHJ engagement editor Danielle Fox, providing key insights into how well Healthy San Francisco, a health access program intended to ensure coverage for every city resident, worked for them. 

I had also already done extensive outreach to community groups and elected officials, distributed flyers, and obtained a dataset on the program’s enrollment and disenrollment — which took a little prodding but no records request. Knowing that an overwhelming majority of patients spoke Spanish, I had established a partnership with El Tecolote, a 50-year-old bilingual paper, to translate and share the project with their audience, hiring bilingual reporter Jacqueline Pinedo to ensure monolingual users were consistently included.

A reporting plan was set, and all that needed to be done were final interviews, some more data analysis with my senior fellow Meghan Hoyer, and to write a draft. 

Fortunately, Jacqueline and I had accomplished by then a majority of on-the-ground outreach because we came to realize that very few people wanted to be near a hospital at that time. This was about a week after the first local recorded cases of novel coronavirus were publicized. The following week, five Bay Area counties including San Francisco would take the unprecedented step placing its residents and businesses on lockdown to stem the spread of COVID-19. 

That meant the project was placed on a long and uncertain pause while the world as we knew it turned upside down and reporters scrambled to make sense of it. But allowing time to understand how a program designed to provide low-income people with health care handled the stress test of a pandemic disproportionately impacting low-income people and people of color made for a stronger project in the end. 

Healthy San Francisco launched in 2007 as a first-of-its-kind attempt by a city to provide universal care, but never set out to be full insurance. Low-income San Franciscans may tap into the program when they have no other options.

Just three years after its launch, those options greatly expanded with the dawn of the Affordable Care Act, the landmark health care reform law that subsidized care for low-to-middle income households. Healthy SF dropped from a peak of 54,000 enrollees and has held steady at roughly 13,000 patients since.

I took special interest in the program at a time when I was counting down to my 26th birthday, when I would be kicked off my mother’s insurance plan and my employer of two years continued to deny me coverage despite my pleas. Were it not for Covered California — as expensive as it was — my sole option may well have been Healthy SF. 

Federal and state eligibility requirements for public coverage continued to expand, bringing in undocumented youth in California, for instance. So why was Healthy SF enrollment so stubbornly flat? Who were the people who still needed the program? 

What I came to find by analyzing enrollment data from before and after the pandemic was that about 71% of 13,824 patients identified as Hispanic, and the average age of people who used the program is 44. Immigration status reporting was incomplete, but 8,547 said they were not legal permanent residents, and many of these residents were long-time users of the program.

Testing studies done early on by the Latino Task Force and University of California San Francisco found that a disproportionate amount of people infected with COVID-19 were Latino and lacked a primary care provider. 

But even with a program like Healthy SF, many of the people who need it most are not connected to care or may simply have never known they were eligible. One long-time patient, a monolingual Spanish speaker who is undocumented, didn’t know her husband was eligible until she contracted coronavirus from the now-deceased elderly woman she cared for.

Organizers were finding that many Healthy SF patients either didn’t know their coverage status, were kicked off after being unable to afford fees, or could not reached because they could no longer afford phone service. The program eventually extended renewal periods by 180 days.

And despite the pandemic being the catalyst for mass layoffs and losses in medical insurance, city health funds collected under a 2006 law — funds intended to help San Francisco workers without employer-provided insurance — rose to a staggering $409 million in October 2020 from $359 million earlier that year. Many workers are unaware they can access these funds collected in their name, as I also reported as a component of the fellowship.

Healthy SF enrollment also fluctuated toward the beginning of 2020. In January, the program had 13,657 patients; by April that went down to 13,130 and then rose to 13,824 by September.

Ultimately, the pandemic has proven that in San Francisco and nationwide, medical care and safety net programs are not reaching low-income and immigrant communities.

It’s probably inadvisable to superimpose lessons learned from a fellowship interrupted by a pandemic for more general reporting. But a few things have stood out through my reporting that do: 

—Data analysis can prove invaluable for revealing the triumphs and failures of a particular issue, when done carefully and with the right skills.

— Understanding how something written on paper translates to people on the ground is key, and community organizers are vital in helping you do that.

Most importantly, bilingual reporters are greatly needed in newsrooms. The fellowship allowed me to hire Jacqueline but it shouldn’t be a special circumstance. When people and their stories are lacking or altogether left out of coverage of important and ongoing issues, we get a very different picture of the world and our communities have been worse off because of it.