Frustrated with the City's Safety Net

San Francisco’s public health program, Healthy San Francisco, serves nearly 47 thousand uninsured patients. Some of those patients are young, educated professionals, the subject of a three-part series we are reporting. Last week, we learned why nearly a third of Americans aged 19 to 29 are uninsured. 

ANDREW HOFF: I’m on a pretty fixed income, so to have to pay this money for comprehensive health insurance on a monthly basis – it’s just not a reality. 

HOST: That’s Andrew Hoff. He was 25 and uninsured when he fractured both of his elbows in a bike accident. He went to San Francisco General Hospital and says received great care. 

HOFF: And so I don’t really understand, if this resource is out there for people, why get health insurance. (Laughs) 

But not everyone has such a good experience with the city’s public health care system. A recent survey by the independent Kaiser Family Foundation gave Healthy San Francisco very good marks for patient satisfaction overall, but also found some issues. Nearly a third of participants said at least one aspect of getting care is more difficult now than before they joined the program. And about a quarter say they have delayed treatment or had problems getting care. Today, KALW’s Zoe Corneli brings us the story of one uninsured patient who has found her experience with the city’s safety net frustrating. And, a note to our listeners: the patient’s name and voice have been changed to protect her privacy. 

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ZOE CORNELI: Lisa Smith is showing me where she spends most of her time. 

LISA SMITH: Okay, we’re gonna head down into the garage, watch your head, you might bump it. 

CORNELI: Smith ducks through a small doorway, walks past twisting ducts in a dark, unfinished storage room, and finally emerges into a clean, bright space.  

SMITH: My landlord’s really cool, he lets me use the back half of the garage. 

CORNELI: This is Smith’s art studio. A hanging white bed sheet separates her drawing table, paints and pencils from her neighbor’s parking space.  

SMITH: I feel very lucky, ‘cause a lot of people have to pay like $300, $400 for a studio space and also for rent, so I feel pretty lucky that I have it all in my home. 

CORNELI: Smith earns about $15,000 a year selling her art and doing contract work for museums and a frame shop. In between gigs, she gets unemployment. She says it’s not a lavish lifestyle, but it works. 

SMITH: I go to the library a lot, I shop second-hand… I’ve figured out how to get by on very, very little. (Laughs) 

CORNELI: Her budget doesn’t have room for big medical expenses. 

SMITH: I can’t imagine adding on four or five hundred dollars a month for insurance. 

CORNELI: But Smith does have a minor thyroid condition that requires daily medication. About twice a year, she goes in for blood tests. So when she found out about the Healthy San Francisco program last year, she decided to enroll. She received a handbook and a membership card with a phone number for a clinic that provides primary care. But from the moment she got her materials, Lisa Smith says she had trouble navigating the system. 

SMITH: When I first got it I tried to make an appointment, and I was on the phone, and leaving voicemails, and the card that they gave me wasn’t—they had changed the number, and I was having a really hard time connecting, you know kind of like when you call the phone company or the electricity company, where you’re just on hold and you’re feeling like no one’s noticing that you’re waiting. And then when I did get the appointment, it was for months in advance. 

CORNELI: Rather than wait, Smith decided to go to the Haight-Ashbury Free Medical Clinic. It’s not affiliated with Healthy San Francisco. Doctors there volunteer their time to see patients who don’t have insurance and can’t afford to pay full price. 

SMITH: And you know, it’s like mostly people who are addicts, or people that are kind of homeless and living a pretty extreme, rough life, and you walk in you kind of have to sit with them, and I waited, you know usually have to wait in the waiting room for half an hour, 45 minutes, and then when I went in, he checked my blood pressure. 

CORNELI: She told the doctor her medical history. 

SMITH: And then at the very end he said, okay, you have to go to General Hospital, to actually get the blood test, because they didn’t run blood tests at Haight Street because of money problems. 

CORNELI: So she made an appointment, and two weeks later, she went to SF General.  

SMITH: Yeah that place is so Kafkaesque, cause I remember, you take a number, and you sit down, and it’s just this sea of people, and you have to bring a book or you’ll go insane. 

CORNELI: Two weeks after that appointment, Smith got her results in the mail. Rather than schedule yet another appointment, she short-circuited the system by asking her cousin, a doctor with Kaiser Permanente, to review the results. 

SMITH: You know it’s just a little reassuring to have someone that loves me, cause I don’t feel like people kind of really care, like they could totally screw something up, and I would be sort of not able to protect myself. 

CORNELI: Smith says she’s just not confident she’s getting the level of care in the public system that she should be. Healthy San Francisco Director Tangerine Brigham says Smith should have let the program know about her negative experiences. 

TANGERINE BRIGHAM: Because we can’t quite frankly improve the system, unless people give us that kind of feedback.  

CORNELI: Still, Brigham says all patients should expect quality health care.  

BRIGHAM: So our expectation is that we deliver quality care, and we’re gonna be looking at the measures that’ll help us determine that. 

CORNELI: The Healthy San Francisco program is only two years old. While it has been collecting data all along, it just started its first major quality evaluation in July, and that will take two more years to complete. So it’s too early to compare its effectiveness with other health care options. Brigham says the program has already taken measures to make the system easier to use, but some challenges are unavoidable. San Francisco’s public safety net serves a population that is older and sicker, on average, than the general population. Brigham says many of the patients are homeless and may have multiple serious diagnoses, such as HIV/AIDS and mental illness. 

BRIGHAM: We certainly try to make sure that they are in an environment which is not offensive to others, but I think that when you are dealing with a homeless population, that you are gonna get some things in a clinic that you might not receive in a clinic that doesn’t serve a homeless population. I don’t think that that reflects badly on a program. I think that reflects on a larger issue in our society where we don’t have sufficient systems in place to care for people that are homeless. And quite frankly, we value the notion that there’s some place where people can go to get care. 

CORNELI: And Lisa Smith is among those who need some place to go.  

It’s been a year since she first signed up for the program, and now, she’s worried she won’t be able to re-enroll. She had to make an appointment to verify her income. And she’s concerned  that because of the feast-or-famine nature of her work, she’ll be asked to pay more than she can afford. 

SMITH: I can’t really verify to them how much money I’m going to be making monthly to monthly, you know either I don’t have any money at all, or if I have some, they’re going to expect a lot, and I’m trying to make that money last as long as I possibly can, you know. 

CORNELI: Today, Smith is downtown at the San Francisco Health Plan offices for her re-enrollment appointment – and she’s got a nasty cold. Application Assister Judy Ramirez sits down with Smith in a bright, clean office to go over her income documents. 

JUDY RAMIREZ: Okay, so you were enrolled previously in Healthy San Francisco? 

SMITH: Right.

RAMIREZ: Okay. So let’s see. Okay so if I could take a look at your paperwork. 

SMITH: Sure. Here’s a bank statement, here’s some pay stubs, and this is tax return information for 2008. 

RAMIREZ: Okay. Has your income gone up or down since last year? 

SMITH: Um, it’s kind of unusal… 

CORNELI: Smith explains she just finished a major freelance gig, but she hasn’t been paid for it yet. 

RAMIREZ: There’s many like W2s and different receipts, so we might wanna go with your pay stubs. We’ll be able to use this unemployment stuff.  

SMITH: Okay. 

RAMIREZ: My goal is to make sure we get an idea of their average income. In her case, perhaps last year maybe she made more money, we don’t know that right now, so we’re gonna use her unemployment stub instead because this is gonna be more accurate. We definitely try to avoid fees for our members, because if they don’t pay their fees, then they get disenrolled from the program. So it was 152 that you were receiving on a weekly basis from unemployment? 

SMITH: Yeah. 

RAMIREZ: Okay, the good part is, including your assets and your unemployment, you don’t have to pay a fee to the program right now. 

SMITH: Oh great. 

CORNELI: And with that, Lisa Smith’s membership is renewed for another year. But she has one more question. 

SMITH: I’ve been having things that I kind of wonder if I need to go to an endocrinologist for – I’d have to go to my clinic and they’d have to refer me to General Hospital maybe? 

RAMIREZ: Um, here in our handbook, we have a page on specialty care. You may not see a specialist without a referral from your medical home. 

SMITH: Right, right. 

RAMIREZ: So you definitely want to have that, to go see a specialist if it’s outside your medical home. 

CORNELI: Outside, after her appointment, Smith says she’s relieved and grateful to have coverage in case of an emergency. But while the program is billed as preventive care, the prospect of working her way through the system discourages Smith from making an appointment for anything less than dire. 

SMITH: A part of me is just sort of like, I’ll just put up with my suffering until it gets worse. And maybe then I’ll go. (Laughs) 

CORNELI: And she’s not optimistic about getting to see that endocrinologist. 

SMITH: Like I feel like um, I have to um like get myself ready, go out and fight, it’s a concerted effort. You know it’s not gonna be easy. And um, we’ll see, maybe I’ll try, but it’s just um. A little exhausting. It’s not something I’m looking forward to doing. It’s not something that I feel good about doing.  

CORNELI: So for now, Smith will fall back on her usual standbys: eating healthy, exercising and getting enough sleep, until the day when she can afford to pay for health insurance. 

SMITH: I just hope I don’t get sick very often. (Laughs)  

CORNELI: In San Francisco, I’m Zoe Corneli, for Crosscurrents.