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Q&A: Measure F and Stanford Health Care

An initiative on the November ballot in the City of Palo Alto would significantly affect the delivery of health care within the city, including at Stanford Health Care. Three university leaders discuss the issues behind the initiative and the impacts they foresee.

(From left) David Entwistle, Mary Hawn and Randy Livingston.

Voters in the City of Palo Alto will see an initiative on their ballots this November that has significant implications for Stanford Health Care.

If approved by voters, the initiative, known as Measure F, would limit the amount that health care providers in Palo Alto can charge commercially insured patients to 15 percent above the provider’s “direct” costs for patient care.

The measure would apply to Stanford Health Care, Palo Alto Medical Foundation and other medical clinics in Palo Alto, as well as local doctors, dentists, optometrists and small, specialty clinics.

Stanford has taken a position officially opposing Measure F “because it would threaten Stanford Health Care’s ability to provide top-quality health care to patients from Palo Alto and across the region,” according to a university statement. The Palo Alto City Council recently voted unanimously to oppose the initiative. The university also opposes the similar Measure U in Livermore, where Stanford Health Care operates ValleyCare Medical Center.

Stanford typically takes positions on external political issues only when they directly impact the university’s mission. However, the university also encourages members of the university community to review the facts and make an informed decision for themselves. Stanford Report asked David Entwistle, president and chief executive officer of Stanford Health Care; Mary Hawn, MD, chair of the Department of Surgery in the School of Medicine; and Randy Livingston, the university’s vice president for business affairs, chief financial officer and liaison for Stanford Medicine, for their perspectives on Measure F.

Q: In a region with such a wide range of hospitals and clinics, what is Stanford Health Care’s role?

Entwistle: Stanford Health Care is the only level-1 trauma center between San Francisco and San Jose, and specializes in the treatment of rare, complex diseases and disorders including cancer treatment, organ transplantation, neurosciences, cardiovascular health, orthopedic surgery and other surgical services.

As a world-class academic medical center, we draw patients not only from our region, but from around the world. They come to our campus for the innovative, high-quality care that only we can deliver. Patients turn to Stanford Health Care when it matters most to them, and our doors are always open, regardless of personal circumstances. We work with patients to ensure they get the care they need, when they need it.

Q: How would Measure F impact Stanford Health Care?

Entwistle: If passed, Measure F would require Stanford Health Care to pay rebates to insurance companies for charges to commercially insured patients more than 15 percent above the cost of “direct” patient care.

A critical subset of additional expenses covered by providers, including facilities operations, technology costs, management expenses and other types of necessary overhead, could not be factored in to the cost of care under this initiative. Measure F also fails to account for the losses that providers incur when they treat patients insured through Medicare and MediCal and those who aren’t insured. Today, providers recover these losses in part through the care they offer to commercially insured patients.

Such a policy is estimated to reduce Stanford Health Care’s budget by 25 percent — requiring significant cutbacks and the possible closure of many services and programs that are essential to high-quality health care in the local area.

This type of drastic restructuring would fracture our high-quality patient care models — forcing reductions of our indispensable health care team members. These reductions may include physicians, nurses, clinicians, educators, managers and others who help patients and their families cope with the difficult issues that accompany serious illnesses and injuries. It would also force us to reconsider how to use the new hospital building that is slated to open next year and eliminate our ability to retrofit current facilities. It would also threaten our status as a top academic center that supports research and education.

I want to emphasize: This initiative actually does nothing to limit the prices charged to patients with insurance coverage. Nothing in the initiative improves health care quality or patient safety. And nothing makes care more accessible to low-income and vulnerable groups.

Measure F was developed and promoted by Service Employees International Union-United Healthcare Workers West (SEIU-UHW). The measure poses far-reaching, negative consequences for a broad range of health care providers, the Palo Alto city government and, ultimately, the patients and people we care about and serve.

Q: Why has the university taken a position on this initiative?

Livingston: It’s important first to understand that Stanford deeply values and respects the broad diversity of opinion and viewpoints in our community. As a general principle, the university takes institutional positions on external political matters only when they directly affect the mission of the institution itself. We believe Measure F clearly does.

Measure F threatens Stanford’s commitment — through Stanford Health Care — to serve our community. It strikes at the heart of the charge in our founding grant to “promote the public welfare.” High-quality health care is clearly a significant part of what Stanford contributes to the region we live in. We hear often from members of the community how highly they value having an institution like Stanford Health Care in their community.

On top of that, our own campus community of faculty, students and staff depends on the availability of high-quality health care in the immediate local area, both through Stanford Health Care and other providers. Access to this health care for the people of our community is critical to the university’s success. We believe it’s clear that this measure would force Stanford Health Care and other local health care providers to make extremely difficult decisions to close or reduce programs, deeply affecting the availability of care locally.

Q: What would be the impact of Measure F on Stanford’s neighbors in Palo Alto?

Livingston: First is the impact on care. We are proud of the role that Stanford Health Care plays in providing local communities with the peace of mind that comes from accessible, top-quality health care close to home. Measure F stands to jeopardize that — not just for Stanford Health Care, but also for Palo Alto Medical Foundation and other clinics and hospitals, even local dentists and eye doctors. But it wouldn’t just severely limit access to care.

Measure F would also place a tremendous financial and administrative burden on the City of Palo Alto. The City Council voted unanimously to oppose it. Mayor Liz Kniss, who is also a nurse, signed a letter with other health care professionals that said Measure F would fail to improve health care in the city — yet, at the same time, it would force the city to raise taxes, reduce city services and/or lay off employees. That’s a lose-lose proposition for everyone.

Q: People in the Stanford community may have heard radio ads criticizing the infection rates at Stanford Health Care. What should the university community know about this?

Hawn: SEIU-UHW has spent nearly a million dollars on a series of ads to attack our patient care and quality. These ads unfairly criticize our employees and their hard work by using outdated data.

For example, one ad cherry-picks a rate for C. difficile infections from 2014 that doesn’t represent our current, much improved outcomes. In fact, that rate dropped by 45 percent between fiscal years 2014 and 2018 to date. In the last fiscal year alone, hospital-acquired infections decreased by 30 percent, and length of stay decreased by 12 percent.

Hospital-acquired infections and other quality issues are a challenge across the health care system, particularly for academic medical centers, whose patient populations contain many more complex cases where infection is a substantially higher risk. Today, we have over 120 unique safety and quality initiatives incorporating the expertise of clinicians, patients and infection control physicians. Our online resource,, has more information about our record and commitment to patient safety.

Q: What is Stanford’s approach to infections and patient safety?

Hawn: As an academic medical center, Stanford Health Care provides care for some of the sickest patients in the world. These very ill patients with complex conditions are particularly prone to health care-associated infections due to their frailty and vulnerability, and we continually seek to protect them by improving our already excellent infection control.

At Stanford Health Care, patient care as well as patient support departments and services participate in comprehensive infection reduction and prevention programs. Hospital committees and task forces focus on decreasing hospital-acquired infections such as central line-associated bloodstream infections, catheter-associated urinary tract infections, and C. difficile infections. Efforts also include focused surveillance, such as identification and tracking of hospital-acquired infections, compliance with process measures and monitoring for necessary corrective actions.

Despite receiving some of the sickest patients, we maintain very positive outcomes — even compared to hospitals that treat patients with less severe illnesses. This is because we go to extraordinary lengths to provide safe, clean environments. And we continue to make great strides when it comes to infection prevention and control efforts.

Stanford Medicine integrates research, medical education and health care at its three institutions - Stanford University School of Medicine, Stanford Health Care (formerly Stanford Hospital & Clinics), and Lucile Packard Children's Hospital Stanford. For more information, please visit the Office of Communication & Public Affairs site at

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