"Obamacare is a big failure, and it has to be changed. We have to go to a plan that works.”
President Donald Trump
Contrary to this statement and many like it, my experience is that Obamacare is, in fact, working. Recently I met a new patient in my primary care practice. He was a young man in his 40s who until recently drove for Uber and Lyft. That all changed when he came down with a severe case of meningitis that included an extended stay in the hospital, including intensive care and rehabilitation. Impressively, and unlike many men his age, he was devoted enough to his health to show up to a primary care appointment in order to ensure his health continued to improve following his inpatient stays. I reflected on how challenging his situation would have been financially if he hadn’t had Medi-Cal coverage, and how that would have impacted everything in his life and with his health. Had it not been for the ACA, he would have been uninsured.
The ACA has had a huge impact on all San Franciscans. Today only 4.8% of San Franciscans are uninsured, compared to 9% in the U.S. 93,000 additional people received assistance through the Medicaid coverage expansion and another 40,000 newly enrolled in insurance through Covered California. These individuals now are more likely to have better health, and less likely to suffer devastating financial crises as a result of medical bills.
This young man received all his care – including his primary care appointment with me – at the Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG). ZSFG is a hospital and hospital based clinic system which provides acute care, psychiatric care, skilled nursing care, primary care and a network of outpatient specialty services. As the only Level One trauma center for San Francisco and northern San Mateo County and the only psychiatric emergency service, it also provides essential community services. ZSFG serves almost 110,000 individuals annually, providing to them more than 70,000 emergency department visits and more than 550,000 outpatient visits among many other services. We are an essential training facility for thousands of medical, nursing, pharmacy students and residents. We have had a 150 year relationship with the University of California, San Francisco (UCSF), and are home to about 1500 doctors and other UCSF staff. We are part of the City and County of San Francisco’s Department of Public Health (DPH), and employ almost 3500 staff through the DPH. Through the DPH, we are part of a broad network of community health services.
The ACA has had an enormous impact on ZSFG at a time when imperatives for the way we provide care have fundamentally changed. This is best characterized the earth-changing move from a pay for volume to pay for value paradigm, value being defined as the highest quality care and the best patient experience at the lowest possible cost. This is true for most hospitals as a result of payment changes such as the Medicare Comprehensive Care for Joint Replacement (CJR) program. For safety net hospitals in California, the even bigger impact comes as a result of the California Medi-Cal waiver. For ZSFG, this is worth almost $150 million per year in supplemental Medi-Cal payments, all of which are pay for value. For example, in order to be paid, we must meet scores of ambitious targets for controlling blood pressure and diabetes, providing an excellent patient experience, and counselling about tobacco use, among other things.
Since 2012-13, at ZSFG our payor mix has improved dramatically: for example, our inpatient uninsured rate has gone from 39% to 3%, while our Medi-Cal reimbursement has risen from 35% to 50%. In addition to stabilizing our ability to remain an essential community care resource, this additional revenue has enabled us to invest in systems and programs in order to become a provider of choice. If we had not had these resources, we would not have been able to invest in a desperately needed enterprise-wide electronic health record, nor would we have been able to provide health services in our new acute care building.
We are already starting to see the results of this improvement in our revenue streams in all types of care we provide. Some examples: In the last year for the CJR program, the percentage of patients we discharge home (a measure of increased quality) has increased from 23% to 62%. In 2013, almost half of specialty care clinics had a time to third next available appointment (TNAA) of more than 60 days. Three years later, in 2016, more than 90% of specialty care clinics had a TNAA of less than 15 days. In the past year, ZSFG had no catheter associated urinary tract infections in the medical intensive care unit.
These are among the reasons Obamacare works, especially for the most vulnerable among us. Through all the political discourse, I hope we remember the ACA has had tremendous beneficial impacts not only on essential community institutions, like ZSFG, but on the individuals it serves. The young man I took care of, and many thousands more like him, deserve to have the resources they need to be healthy.