Proposition A - Hospital Bond

Voter Guide
This measure appeared on the November 2008 San Francisco ballot.


What it does

Proposition A is a measure that appropriates $887.4 million in general obligation bonds for the building of a new acute care hospital and trauma center at San Francisco General Hospital. Acute care refers to short-term patient care, often done in emergency room settings. A 1994 state law requires seismically unfit acute-care hospitals, such as SFGH, to be rebuilt by 2015.

Bond funds are proposed to pay for a number of uses:


$717.1 million

Regulatory/city agencies

$11.16 million

Management/administration/design/other soft costs

$139.25 million


$19.89 million

These funds would pay for a new hospital between two sets of historic red brick buildings fronting Potrero Avenue. The new building would have approximately 442,000 square feet of space with 284 general acute care beds, an increase from the current 252 beds. The building would have nine stories. To accommodate all necessary functions within zoning height limits, two floors would be built underground. The underground floors would extend as far as the brick buildings on either side, while the above-ground floors and patient rooms would extend to within 40 feet of those buildings.

The old hospital and its 252 beds would be reused for non-acute care and psychiatric inpatient services.

If Proposition A is approved, site clearance would begin in the summer of 2009. The foundation and structural framework would begin in January of 2010, and build out of the building enclosure would come by summer of 2011. Remaining construction is planned to take approximately three years, meaning the building would be open and operational before January of 2015, in time for the state deadline.

Why it is on the ballot

Prop. A was placed on the ballot by a unanimous vote of the Board of Supervisors. General-obligation bonds require the approval of two-thirds of the voters in an election.

Prop. A is a response to a 1994 state law that requires upgrading or replacing seismically unsound acute care hospitals throughout California. During the 1994 Northridge earthquake, more than 100 hospitals throughout the Los Angeles area were damaged, with some literally being shaken off their foundations. As a result of that experience (as well as the 1989 Loma Prieta earthquake), the state passed Senate bill 1953 in 1994. That law requires all acute care hospitals to be upgraded or replaced by 2013 (or 2015, if planning for the work is well underway). The measure led to new hospital building codes that require upgrading the foundation, structure, materials, safety, energy and other elements of a modern hospital. The requirements are so stringent that for many hospitals, building an entirely new facility is cheaper than retrofitting an old one.

The existing San Francisco General Hospital building is relatively new, dating from the 1970s. However, its rebar/concrete columns and walls are not strong enough to withstand a significant earthquake. Even a moderate earthquake could require the evacuation of patients and the termination of services. Therefore, it is classified as being in the lowest "structural performance" category and may remain in use as an acute care hospital only through January 1, 2015. Beyond that date, its acute care facilities must shut down in accordance with state law, although the existing hospital may be used indefinitely for inpatient psychiatry, outpatient services and myriad hospital services unrelated to acute care.

In planning the rebuild of SF General's acute care facilities, the City considered several alternatives other than constructing a new facility. The first option was to retrofit the present hospital building. This would require major structural changes while continuing to operate it as an acute care hospital. The current hospital building had an extensive structural evaluation and it was found that the cost to retrofit nearly equaled the cost of a new building; there was no good way either to move the patients to another location or continue to operate during construction; and, in the end, the City would have a facility that was functionally obsolete by today's standards.

The second option was to co-locate with the University of California at San Francisco, at Mission Bay. That option would have offered only one emergency service, and possibly with only enough SF General beds for the population served by the City which would not have accommodated the additional demand from UCSF. This option would have required purchasing additional land at a very high cost, as the UCSF parcel is barely large enough to meet its own needs.

The third option was to build a hospital at Mission Bay, yet contract with UCSF (and other city hospitals) to provide full services, retiring SF General in favor of a healthcare coverage program. The City has developed a health plan, now operational, to cover many of the indigent people in the city. This Mission Bay option was not feasible, however, because SF General is required to renew its facility earlier than is UCSF, which has until 2020 to meet the state requirements. In addition, UCSF did not wish to assume the full roles that SF General plays in the local health care system.

A fourth option would be to rebuild the existing campus. This would entail the removal of the old red brick buildings that face Potrero Avenue. This alternative would have had the advantage of not requiring the construction of two underground floors, because it would have allowed the City to build on a larger footprint while still staying within the existing height limits. In addition, it would allow for future expansion.

An above ground location is best for some essential services, especially the operating suite and its necessary radiology, because it reduces the need to transport patients up and down in elevators from the emergency room and trauma center and patient rooms. An above ground location also can better house the highly trained personnel who would otherwise spend their working lives in the windowless basement, and provides a more pleasant environment for patients. This option would also permit the incremental expansion of the operating suites.

A fifth option would be to use the parking lot next to the current hospital, on 23rd Street. This option was considered less desirable because of its proximity to the private homes across the street. The residents did not want the additional traffic on their street — traffic that already counts existing ambulance traffic of 15,000 visits per year. That building's shape would have had to be tall and narrow, with constraints on essential departments and circulation. It, too, would have had problems with expansion or replacement in the future. In addition, any new facility built here would have been a tight squeeze up against the existing hospital and would have had to be constructed while the hospital was still caring for patients in the older building.


Arguments in favor of Prop. A:

  • SF General is required to rebuild its acute care hospital with a trauma center, or face closure in 2015. This bond would allow the City to comply with this state law. Prompt funding and action is necessary to prevent SF General from closing.
  • If SF General is not rebuilt and is forced to close, the City would lose care for 100,000 patient days every year, 20 percent of the City's acute care patients. San Francisco also would lose the only trauma center for San Franciscans. SF General's trauma service and emergency room is a citywide asset for all residents, not just the poor.
  • Before it was placed on the ballot, this bond received a level of planning equaled by few bond measures in the City's history. The measure has been analyzed for four years, and the City already has spent $25 million on planning and architectural work.


Arguments against Prop. A:

  • The design and location of the building does not permit any significant modifications to respond to changes in demand or the delivery of medical services. Because the new hospital was designed and will be built as a single unit, it cannot be expanded horizontally or vertically. As the delivery of medical care evolves, the new building will be hard to adapt without a chassis that provides for incremental replacements or expansions.
  • Better alternatives for the building location and design were overlooked to avoid conflict with historic preservation because the City chose to build the hospital immediately between the existing historic buildings. Although these buildings are still in use, they are seismically unsafe and functionally obsolete. They house research functions, which could have been relocated. Building the new hospital directly between the existing buildings makes it more expensive to build and prevents expansion in the future.
  • The building's design includes uses in the two basement levels that should operate above ground. These basement levels include essential services such as the operating suite, its accompanying procedure rooms and invasive diagnostics. These should be located above ground, which would benefit the large number of outpatients. In addition, the underground location precludes any future expansion of surgery areas.
  • Construction cost escalation may exceed the projected 7 percent per year estimated in the SF General capital plan. The usual strategy when medical facilities must adjust the size of the project to the amount of money available is to reduce the number of beds or the volume of services. The building as designed is a single unit that cannot easily be reduced incrementally.

SPUR’s analysis

SPUR has been one of the strongest advocates of the City's Capital Planning Program, which now has an open and transparent process of identifying infrastructure needs and setting priorities. San Francisco General Hospital is one of those key priorities. We support the replacement of the hospital, given that its role cannot readily be duplicated by any other hospitals in the city, and that it serves an important population not served as well by other hospitals.

SPUR probably would not have recommended this plan, if we were to choose from among all possibilities. However, after careful and detailed study, we conclude that this proposal is sound and will meet the core objectives of San Francisco's health delivery needs.

Choosing not to rebuild simply is not an option. Further, pursuing other alternatives — such as getting out of the business of a publicly funded facility and asking private hospitals to pick up the type of patients served by SF General — likely would not be successful and would result in major increases in patient costs at the private hospitals. Even if those hospitals were to take on more uninsured patients than they do now, their medical staffs do not have the same charitable obligation or experience as the staff of SF General.

Ultimately, San Francisco General Hospital has an important and special role in this city, particularly for patients who do not have the financial means to access the same quality of care from private facilities. Rebuilding the acute care hospital would allow the continuation of this care and maintain the existence of a Level I Trauma Center in San Francisco.

SPUR recommends a "Yes" vote on Prop. A.