In a three- to five-page essay, describe and analyze the new health care system

initiatives in the state of Massachusetts and in San Francisco, CA . Compare the

initiatives in terms of function, cost and outcome. Based on the narrative in the

text, and information you can find on the Internet, do you think they should be

replicated in other parts of the country? Defend your answer.

This essay will analyze the new healthcare system initiatives in the state of

Massachusetts and San Francisco, CA, with respect to the Massachusetts healthcare

reform law and the San Francisco Health Care Security Ordinance. This essay will

analyze these initiatives in terms of function, cost and outcome, and argue that they

should be replicated in other parts of the country, although care should be taken to

ensure that costs are controlled and managed effectively.

Massachusetts

The Massachusetts healthcare reform law (2006) provides health insurance to all its

residents, and ensures free or subsidized insurance for residents earning less than

300% of federal poverty level, while also mandating employers to provide healthcare

insurance. In terms of function, the healthcare reform law aims to ensure equitable,

quality access to affordable healthcare for all Massachusetts residents. In terms of

outcome, this has led to high rates of health coverage, and has ensured that an

overwhelming 98% of Massachusetts residents are covered by healthcare insurance.

The extent of coverage by these new health initiatives were eventually so successful

1
that they were adopted at the national level as part of the Affordable Care Act, more

popularly known as ‘Obamacare’.

These new healthcare system initiatives, however, have led to unintended outcomes.

For example, according to economists Kolstad and Kowalski, Massachusetts jobs with

employer sponsored healthcare pay almost $3,000 less annually, with deadweight loss

of mandate-based healthcare reform of 8 percent. Furthermore, research has shown

that uptake on the Massachusetts state health insurance scheme has been lower than

expected, which may point to the need for greater awareness and education campaigns

by state healthcare authorities.

Additionally, in terms of costs, the Massachusetts healthcare reform has fallen short.

Ballooning costs have seen the Massachusetts healthcare budget between 2013 to

2018 increased by 42%, and the Massachusetts Health Policy Commission estimated

that there was between $12 to $22 billion in wasteful health care spending due to

bureaucratic complexity, inability to coordinate resources well and overapplication of

treatment. Clearly, this is a system that needs to be better designed and administered in

order to streamline what are becoming rapidly unsustainable costs. Fortunately, new

healthcare initiatives by the Massachusetts state legislature have sought to restrict and

streamline healthcare system costs. For example, ‘Chapter 224’ legislation has been

unveiled since 2012 in order to limit private and public healthcare spending.

2
In the case of San Francisco, the San Francisco Health Care Security Ordinance and

the ‘Healthy San Francisco’ health care initiatives were rolled out as novel approaches

to universal health care coverage. In terms of function, these initiatives were meant to

extend healthcare coverage to the uninsured, mandate that employers must pay toward

employees’ healthcare service costs, and strengthen the use of primary care and the

common electronic enrolment system. In particular, Healthy San Francisco was meant

for those under 5 times the Federal Poverty level who had gone without proper

healthcare insurance for three months. They could choose any of the 30 designated

health clinics in the city and be assigned dedicated healthcare practitioners, with their

data stored in a citywide database so that records could be easily transferred between

different healthcare providers.

In terms of outcome, according to the United States Census 2016 American Community

Survey, 97% of San Franciscans are now covered by healthcare systems in the county,

which far exceeds the Californian state average of 93%. The City Option, which

provides limited healthcare services for uninsured that do not qualify for uninsured

healthcare programs, also covers the remaining 3%. These new initiatives have also

strengthened primary care and reduced emergency room visitation times.

However, some outcomes for the San Francisco health initiatives have been negative.

These initiatives were designed as temporary measures to ease individuals into a

transition to ACA, or Obamacare, insurance. When Obamacare started to run into

trouble, the unsustainable nature of these health initiatives was revealed. Furthermore,

3
these initiatives suffered from a shortfall in funding from private corporations and

employers.

The coverage of Healthy San Francisco was also not broad enough for several patients.

Healthy San Francisco emphasizes preventive care, specialty care, routine visits,

urgent/emergency healthcare services, hospital treatments, alcohol and hard drug

abuse care, lab tests, mental health treatment, and prescription drugs, but does not

include dental and vision care. As a result, many patients on the Healthy San Francisco

scheme were unable to access supplementary healthcare services.

Furthermore, San Francisco’s heavily subsidized health insurance schemes may also

be difficult to afford for low income individuals, especially those who have to first pay out

of pocket at the point of service.

Finally, San Francisco’s healthcare initiatives were not adequately completed by other

holistic healthcare initiatives such as healthy eating or anti-drug campaigns. The San

Francisco Cancer Initiative, a community initiative to reduce the burden of cancer, is

one such project, but there were few others besides.

In terms of cost, like Massachusetts, San Francisco has struggled to keep up with rising

costs for its new healthcare initiatives. The California Department on Public Health

relies on significant federal grants for health innovation to fund its healthcare system;

which is reliant on political support that may change between administrations. The

4
current Trump administration, for example, has placed healthcare access and

healthcare system reform low on its list of legislative priorities.

Low patient payments and decreasing employer funding also continue to impose strain

on financing of California state healthcare. Finally, the system remains overly reliant on

other stakeholders such as businesses, patients, federal government and healthcare

providers in order to keep Department of Public Health spending at $100 million

annually. Reports suggest that true universal health care, if implemented, projected to

cost California a tremendous $400 billion a year, which is financially unsustainable.

In conclusion, the new Massachusetts and San Francisco health initiatives are

commendable projects that seek to increase the coverage of universal healthcare

insurance, and should be replicated in other states. This has led to drastically improved

public health outcomes. However, both systems have suffered from excessive costs,

and caution should therefore be taken with regard to cost of implementing such

healthcare systems in other states, especially for states which do not have the same

level of fiscal resources as San Francisco and Massachusetts.

References:

5
Angela Hart, 'The price tag on universal health care is in, and it’s bigger than

California’s budget.' Sacramento Bee, May 22, 2017.

https://www.sacbee.com/news/politics-government/capitol-alert/article151960182.html

Anthony, Barbara, Celia Segel, and Hallie Toher. "Beyond Obamacare: Lessons from

Massachusetts." J. Health & Biomedical L. 14 (2018): 285.

Carroll, David, Dylan H. Roby, Jean Ross, and Michael Snavely. "What Does It Take

For a Family to Afford to Pay for Health Care?." (2007).

Eslami, Mohammad H., Katherine Moll Reitz, Denis V. Rybin, Gheorghe Doros, and Alik

Farber. "Improved access to health care in Massachusetts after 2006 Massachusetts

Healthcare Reform Law is associated with a significant decrease in mortality among

vascular surgery patients." Journal of vascular surgery 68, no. 4 (2018): 1193-1202.

Hiatt, Robert A., Amanda Sibley, Laura Fejerman, Stanton Glantz, Tung Nguyen, Rena

Pasick, Nynikka Palmer et al. "The San Francisco Cancer Initiative: a community effort

to reduce the population burden of cancer." Health Affairs 37, no. 1 (2018): 54-61.

Jacobs, Ken, and Laurel Lucia. "Universal Health Care: Lessons From San Francisco."

Health Affairs 37, no. 9 (2018): 1375-1382.

6
Joseph, Tiffany D. "What health care reform means for immigrants: comparing the

Affordable Care Act and Massachusetts health reforms." Journal of health politics,

policy and law 41, no. 1 (2016): 101-116.

Kolstad, Jonathan T., and Amanda E. Kowalski. "Mandate-based health reform and the

labor market: Evidence from the Massachusetts reform." Journal of health economics

47 (2016): 81-106.

Minkler, Meredith, Jessica Estrada, Ryan Thayer, Lisa Juachon, Patricia Wakimoto, and

Jennifer Falbe. "Bringing healthy retail to urban “food swamps”: A case study of CBPR-

informed policy and neighborhood change in San Francisco." Journal of Urban Health

95, no. 6 (2018): 850-858.

Wong, Edwin S., Matthew L. Maciejewski, Paul L. Hebert, Adam Batten, Karin M.

Nelson, Stephan D. Fihn, and Chuan-Fen Liu. "Did Massachusetts Health Reform Affect

Veterans Affairs Primary Care Use?." Medical Care Research and Review 75, no. 1

(2018): 33-45.