Enrollment in Healthy San Francisco, the city’s healthcare program of last resort for uninsured residents, has grown by 39 percent since this January, according to the San Francisco Department of Public Health.
That increase may be only the beginning, according to city officials and local healthcare providers. As new Medicaid work requirements and eligibility checks enacted under the Trump Administration take effect next year, alongside separate state Medi-Cal restrictions, an estimated 25,400 to 50,500 people in San Francisco are at risk of losing their Medi-Cal coverage by the end of 2027.
Healthy San Francisco was created in 2007, before the Affordable Care Act, to give uninsured residents access to primary and preventive care. The city launched the program at a time when an estimated 60,000 San Franciscans, many of them working adults, lacked health insurance and often relied on the public health system for care. Today, Healthy San Francisco is funded primarily by San Francisco’s General Fund, plus income-based fees paid by patients.
Early evaluations found that Healthy San Francisco improved access to care. At its peak, in the 2010-11 fiscal year, the program enrolled more than 54,000 residents. Not all of them were low-income. Before the ACA, health insurance for self-employed individuals — especially those with pre-existing conditions — could be prohibitively expensive.
It also had significant drawbacks. Unlike health insurance, Healthy San Francisco only worked within city limits. A patient who broke their leg in Oakland, for example, would have to travel back to San Francisco in order to have their treatment covered.
Enrollment fell below 3,000 by the end of 2025, as residents gained insurance through the Affordable Care Act and subsequent Medi-Cal expansions. Today, adults who live in San Francisco, are uninsured, have household incomes at or below 500 percent of the federal poverty level and are ineligible for public insurance, such as Medi-Cal or Medicare, may qualify for Healthy San Francisco.
Currently there are around 261,000 San Francisco residents insured through Medi-Cal.
At a Sept. 14 City Hall hearing, Tangerine Brigham, chief operating officer of the San Francisco Health Network, a system of public clinics and hospitals run by the city’s Department of Public Health, attributed the sudden spike in enrollment to California’s January freeze on new Medi-Cal enrollment for undocumented immigrants. So far, she added, enrollment had not yet strained the program’s capacity. The city has approved more than $25 million in additional funding to help nonprofit clinics that see patients with Healthy San Francisco coverage, with the expectation that 5,000 to 7,000 new patients could enroll by the end of the year.
Some of those nonprofit clinics are already seeing a spike in patients who have lost coverage. “The crisis is already here,” said Anna Robert, CEO of Mission Neighborhood Health Center, one of 13 independent, nonprofit clinics in the San Francisco Community Clinic Consortium that collectively serve more than 130,000 low-income residents.
The number of MNHC patients with Medi-Cal has declined by approximately 2,000 since January, Robert said. Over the same period, the number enrolled in Healthy San Francisco increased by only 200.
Robert said the clinic has not tracked what happened to each of the 2,000 patients — some may have moved or switched health systems — but MNHC is seeing increases in both uninsured visits and visits by Healthy San Francisco patients.
Healthy San Francisco does reimburse clinics for patient visits, but, said Denisse Porter, MNHC’s chief clinical operations officer, these reimbursements fall short of the actual cost of these visits.
Meanwhile, Porter added, the clinic was seeing more patients miss appointments, and fail to fill prescriptions. MNHC helps patients enroll in and maintain their Medi-Cal coverage, and the clinic’s enrollment navigators are struggling to obtain answers about patients’ pending Medi-Cal applications.
“We’ve established care and relationships and trust with patients for many years,” Porter said. Seeing patients lose access to that care, she added, is “very concerning.”
