San Francisco is an exciting place to be—especially because of its history of progressive politics and culture of grassroots organizing. The city’s passage of the Health Care Security Ordinance (HCSO) in 2006 represented an attempt to implement near-universal health care throughout San Francisco and reaffirmed the city’s commitment to vulnerable people.
No doubt the focus of this legislation on prevention, primary care, and increasing equity in access to care has this UC Berkeley student in public health and doctor-in-training jumping for joy. Through innovative experiments in social responsibility, San Francisco has managed to make leaps in health care reform locally that the federal government can’t or won’t make.
The law’s Employer Spending Requirement is a “play-or-pay” type mandate in which employers “play” by providing health insurance or “pay” by putting funds aside for employees in health or medical reimbursement accounts or to the city for Healthy San Francisco. Given that job-based coverage is still the main way non-elderly Americans receive health benefits, any serious health care reform in today’s political climate needs to work with and build on this system of employer-based coverage—something the HCSO does so strategically. And despite the burden of complying with the ordinance, the majority of San Francisco employers have been shown to be supportive of the local policy.
With the implementation of federal health care reform just around the corner, how will the national Affordable Care Act (ACA) and the local HSCO play out in San Francisco? While the ACA represents a huge step forward for our nation’s health care system, it does not go far enough in fulfilling the dream of quality, affordable, culturally and linguistically appropriate health care for all. One glaring shortcoming of the ACA is the fact that undocumented immigrants are completely left out of health care reform without any real or affordable means of accessing care—except to rely on over-burdened county emergency rooms.
In addition to undocumented immigrants, many others will not be covered under the federal law. Since the ACA employer mandate—which has been delayed until 2015—only applies to employers with 50 full-time employees or more, employers across the country are cutting workers’ hours in order to evade the federal mandate. This trend makes it even harder for people who are trying to work and live in high-cost areas like the Bay Area.
Already well-institutionalized here in San Francisco, the HSCO attempts to fill in some of these gaps. For example, undocumented immigrants who are San Francisco residents are still able to access a regular source of care, as Healthy San Francisco does not require a social security number or ask about status. And since the local Employer Spending Requirement is based on hours worked by an employee, employers have less of an incentive to cut workers’ hours, as they have elsewhere in the country. As such, the city’s policies are an even more vital means of ensuring that low- and moderate-income individuals—particularly immigrants and communities of color—still have a means of accessing robustly funded health care.
If you’re like me and you agree with the need to support San Francisco’s progressive health care policies, join unions, community-based organizations (such as the Chinese Progressive Association), community clinics, and other allies to show your support for the Health Care Security Ordinance this Thursday at 2 p.m. at San Francisco City Hall Rm 250. Your voice matters.
Susan Fang is pursuing an MS and MD at the UC Berkeley-UC San Francisco Joint Medical Program. She was selected as a University of California Human Rights Fellow to work as the Community Health Policy Research Fellow at the Chinese Progressive Association (CPA), which organizes low-income Chinese immigrants in San Francisco.
The views expressed in this blog are not necessarily the views of the Human Rights Center at the University of California, Berkeley, School of Law.
 Jacobs, K. Hacker, JS. “How to Structure a ‘Play-or-Pay’ Requirement on Employers: Lessons from California National Health Reform.” UC Berkeley Labor Center. June 2009 Policy Brief.
 Colla, C. H., Dow, W. H., & Dube, A. (2013). San Francisco’s “Pay Or Play” Employer Mandate Expanded Private Coverage By Local Firms And A Public Care Program. Health Affairs, 32(1), 69–77. doi:10.1377/hlthaff.2012.0295
 Weber, L. “Risky Business: Cutting Workers’ Hours to Save Costs.” The Wall Street Journal. July 15, 2013.