Earthquakes Maybe, But Pre-Existing Conditions or Being Uninsured No Longer a Threat in San Francisco

On this day, April 18, in the year 1906, a major earthquake struck San Francisco, setting raging fires that swept through the city. More than 3,000 people died. My sister is currently visiting from London and cites the risk of earthquakes as one of her main reasons for not wanting to move back to San Francisco. But at this point, I can’t imagine living anywhere else and I can’t imagine being a family physician anywhere else.
I am one of the physicians employed by the City and County of San Francisco to provide primary care to adults under the Healthy San Francisco (HSF) program.  I also provide care to children, adults and pregnant women covered under other programs.  The HSF program was created by City Ordinance in July 2006 and provides uninsured San Francisco residents access to affordable basic and ongoing health care services, including primary care through a medical home, mental health services, specialty and inpatient care, diagnostic services, and prescription drugs. All uninsured adult City residents who are not eligible for other public programs are eligible to enroll, regardless of pre-existing medical conditions. According to a survey of HSF participants in August 2009 done by the Kaiser Family Foundation, “participants overwhelmingly say the reason they decided to enroll in Healthy San Francisco is because they could not afford health insurance or health care services.
Most of my patients are people who have lost their health insurance or have not seen a doctor in years due to lack of insurance. Not surprisingly, once in care they are diagnosed with new chronic diseases like diabetes and hypertension, diseases that they have likely had for years and could have been treated earlier, thereby preventing complications that only make people sicker and ultimately cost us all more. But many of my patients came to me knowing that they already had a chronic disease, but didn’t have the resources to seek care or buy the medicines they need. Others were just afraid to seek care because of known pre-existing conditions. But even though the HSF program doesn’t discriminate against those with pre-existing conditions, the fear of being labeled with one still exists.
My patient, “Pam”, is a 55 year-old woman who was diagnosed five years ago with Multiple Sclerosis (MS), a progressive demyelinating disease. Since then, her disease has worsened and she now has hearing loss but she had lost her job and her health insurance shortly after she was diagnosed. When I first met her about a year ago, she was wearing her deceased mother’s hearing aids because she had no insurance to pay for her own. She had been paying out-of-pocket to get MRIs of her brain under a fake name because she was so afraid of being labeled with a pre-existing condition and thus being denied health insurance. She also has thyroid disease and was buying a medication from India off the internet because she couldn’t afford to see a doctor or to buy the thyroid medication she needs.
During our first visit, she asked that I not write in the chart that she had been diagnosed with MS and refused any testing or referrals. I told her about the new health care law which had just been passed a few months prior and expressed my hope that pre-existing conditions would no longer be something that insurance companies could use as an excuse to deny care. After a long discussion, she agreed to tests, imaging studies, and referrals to specialists. Since then, she has been seen by the appropriate specialists, is finally getting hearing aids, and has had an MRI of her brain that showed that her demyelinating disease is currently stable. Her thyroid is well controlled on the medication that I prescribe for her and she gets under the HSF program. When I last saw her just a few weeks ago, she was happy that all of her medical conditions were stable and under control and was overall doing quite well. She was so confident, in fact, that she told me I could use her real name.
I know that San Francisco is a small city, but I believe that it’s striving to be a city that takes care of its own. As threats to defund the PPACA continue, I’m proud to live in a city that believes that patients should not be denied health care due to pre-existing conditions. I feel incredibly lucky to work for a city that is providing health care services and a medical home to those without insurance. And I can’t imagine living and serving as a family physician anywhere else…even with the threat of earthquakes.