Kia ora tatou

We’re now into autumn here, but the weather has continued to be warm and sunny; winter is going to come as a shock to us I think. I hope it’s warming up nicely in New Zealand and Australia.

It’s a busy time of year here. It’s harvest festival time, which coincided with Halloween at the end of October. For weeks, the shops were selling pumpkins of all kinds and sizes, along with pumpkin beer, ‘boo’ (ghost-shaped) chips, and Halloween greeting cards. Shop windows were well decorated, some with excellent ceramic displays of moving ghosts and vampires. Houses too have been decorated with mock spider webs and spiders, paper ghosts, pumpkins, and skeletons. On Halloween day, the streets were filled with families, with people wearing all sorts of costumes – I saw witches, superheroes, fairies, angels, ghosts, and southern belles – carrying various (but especially pumpkin) containers for treats.

The mid-term elections have also been on, with much campaigning having gone on for weeks for all seats in Congress, and the various senate seats, governorships, and state legislature positions up this year. California will have a new governor in 2011, as current Governor Arnold Schwarzenegger comes to the end of his term. Across the country, the Republicans picked up many seats in Congress, and they will be the majority party in Congress come January. The Democrats still hold the Senate, however. The changes are likely to make it harder for President Obama to continue with his policies, including in health care, which has many health care reform proponents very worried. California bucked the Republican trend, however, electing Jerry Brown (Democrat) as the next Governor.

Californians also got to vote on a series of ‘Propositions’, like the New Zealand referenda that are held now and then. One of the propositions this year was on whether California should legalise recreational marijuana use (marijuana use for medical purposes is already legal for those with a doctor’s recommendations). The focus was very much been on the benefits from reducing law enforcement costs and from the extra taxes legalisation would bring, with very little focus on health issues. However, even if the Proposition had been passed, the federal government had said that marijuana will remain an illegal drug under federal law, and it would go to court to stop the Proposition law from taking effect. As it was, Californians rejected the proposition – 54% to 46%. Another Proposition, if passed, would have suspended air pollution controls – Californians also rejected this proposition, by 61% to 39%. Another Proposition was about whether to change the required two-thirds majority to pass the state budget to a simple majority – this Proposition passed, by 55% to 45%.

And of course sports loom large here as they do in Australia and New Zealand. The local baseball team – the San Francisco Giants – won the National League championship series and therefore went on to play for the ‘World Series’ title (ie. national US title) against the Texas Rangers. Our local bakery was selling SF Giants cupcakes and many shops and houses have had ‘Go Giants’ signs out alongside their Halloween decorations. Seen as a rag-tag team of misfits with a variable performance record, the Giants went on to win the World Series 4 games to 1, in what was a great series of games to watch.

San Francisco then held a huge parade for the team. We joined hundreds of thousands – if not a million – people downtown to watch the parade; all those involved with the team were there, along with marching bands, earlier famous team players in vintage cars, and current team members riding in motorised cable cars. Schools seem to have closed for the day, very few people could have been left working, and the crowd got right behind the team to support their win, with the team also thanking San Francisco for their long support. Links to some of the photos are at the end of this blog. It was great to be there but a bit of a nightmare then getting back home, with trains and buses packed!

On the health reforms front, the Philip R. Lee Institute of Health Policy Studies at the University of California, San Francisco, where I am based, is currently running a series of seminars on health care reform. The second seminar involved a panel discussion, moderated by PRL IHPS Director Professor Claire Brindis, and including Andrew Bindman (Professor of Medicine, Epidemiology & Biostatistics), Mark Laret (UCSF Medical Center) and Diane Rittenhouse (Associate Professor Family and Community Medicine).

Some of the key points I took from the seminar included that:

• Research on alternative models of service delivery has played an important role in showing how things can be different and the potential improvements in quality and reduction in cost that might therefore be achieved by reform, particularly in primary health care and the ‘patient-centred medical home’
• There are significant challenges involved in implementing such complex reform, with changes in roles, responsibilities and regulations at both federal and state level; much of the implementation now lies with states
• Millions of currently uninsured people are expected to obtain insurance coverage over the next few years
• This increased insurance coverage will have a large impact on the demand for doctors, nurses and other health professionals – at a time when there are already significant shortages of trained staff, including in primary health care; ensuring the best mix of staff and the best use is made of clinical staff are therefore key challenges

• There are also challenges ahead for those who currently provide services to people who are uninsured: Will their clients continue to use these services and how should the services evolve? Will other service providers be able to deliver care effectively to this group, which often have specific social and cultural needs?

 
• There is a need for payment reform to ensure payments are fair, and this will play a major role in reducing cost-shifting between programmes

• The medical schools will need to train more people, but they also need to consider the role that non-physician caregivers might play, given the current and likely doctor and nurse shortfalls, and the need for training to promote increased team work

• There remain significant challenges for the legislation and its implementation – but even if legislative changes watering down the reforms are introduced as a result of the Republicans dominating the House of Representatives from January 2011, President Obama is able to veto these. However, funding appropriations to implement key measures may very well be affected, altering the reforms significantly.

We have also continued to do some more travelling. This included a trip to the South West USA. We visited Arches and Canyonlands National Parks, with their beautiful massive red rock formations, and Monument Valley, part of the Navajo Nation, also with beautiful rock formations, and made famous in various western movies, including ‘The Searchers’ directed by John Ford and starring John Wayne and ‘Back to the Future III’.

One of my favourite spots was Mesa Verde National Park, with its cliff dwellings built by the Ancestral Puebloan people – these are the ruins of amazing stone villages set into caves and under rock overhangs on high cliffs, built in the 1200s. We were able to walk down to one of the cliff dwellings and experience what it was like to live in these incredible places.

My other favourite spot was, of course, the Grand Canyon. We visited the more popular South Rim. This was as awe-inspiring as we’d hoped – it’s 446km long, and up to 29km wide across to the North Rim, with layers and layers of different coloured rock making for a stunning sight. The canyon itself is thought to be about 17m years old; the rocks at the bottom are 2 billion years old, about 1.6km beneath the canyon rim. The Colorado River, responsible for carving out the canyon, looked so very tiny from the top of the canyon. The South Rim has a Trail that runs for 19km and is very easily walked along, and there are many trail walks down into the canyon, as well as the famous mule rides down; the walking back up is the challenge, especially given how hot it is on the canyon floor.

We’ve also recently visited Lake Tahoe, in the Sierra Nevada mountains, about four hours drive north-east of San Francisco. The Lake is a lovely blue colour and very clear, surrounded by huge granite mountains. Again there are lots of walks up into the mountains from here, as well as a Scandanavian-inspired castle (‘Vikingsholm’) to visit, camping and swimming in summer, and ski-ing in winter. It was well worth the drive out there, though it was getting pretty chilly at the end of October when we did this trip!

Well that’s all my news for now. I do hope everyone is well and that you have all had a productive 2010. My thoughts go out especially to those living in Christchurch – I do hope that repairs to your homes and workplaces are going well and that the aftershocks will soon stop. Many people here are aware of the quake and have asked how things are; for many who have visited New Zealand, Christchurch is one of their favourite cities and they’re concerned about how the city and its population are doing.
Best wishes, and enjoy the last weeks of 2010!
Jackie

Here you can see pictures of the Parade for the San Francisco Giants, one looking down Market St towards the Ferry Building, the other overhead of the Civic Centre, in front of City Hall.

http://www.sfgate.com/cgi-bin/object/article?f=/c/a/2010/11/04/MNM51G6DMS.DTL&object=%2Fc%2Fpictures%2F2010%2F11%2F03%2Fmn-parade04_PH10_0502503201.jpg

http://www.sfgate.com/cgi-bin/object/article?f=/c/a/2010/11/04/MNM51G6DMS.DTL&object=%2Fc%2Fpictures%2F2010%2F11%2F03%2Fba-giants04_para_0502505306.jpg

Kia ora tatou

Well, hello everyone from San Francisco! My partner, Grant, and I have been here now eight weeks and we are thoroughly enjoying ourselves. As well as delving into the worlds of US healthcare and journalism, we’ve also been coming to grips with simply understanding daily life in San Francisco. We’ve also done a bit of travelling.

We’ve been exceptionally lucky that Grant won a Fulbright Scholarship, allowing us to spend six months here in San Francisco. Grant is based at San Francisco State University and I am at the Philip R Lee Institute for Health Policy at the University of California, San Francisco (a medical school, part of the University of California University system).

Our first few weeks here were rather hectic as we settled ourselves in. At first, we were living in a small studio apartment in Nob Hill, which was very central but had the distinct disadvantage of being up a very steep hill! But from there we were able to explore key parts of central San Francisco, including the Union Square shops, the modern and leafy downtown financial district, Fisherman’s Wharf, and the exhilarating cable cars, which haul passengers up the steep hills with stunning views over the city. We’ve also visited the huge Golden Gate Park, including a wonderful science museum and the de Young art museum, which currently has on an exhibition of impressionist paintings from the Musée d’Orsay in Paris. And we’ve walked across the Golden Gate Bridge, looking out over the Pacific Ocean on one side and the huge San Francisco Bay on the other.

We’ve now moved to a larger apartment in the Noe Valley. This is a gorgeous area full of the lovely Victorian houses that San Francisco is so well known for, with an excellent small village shopping centre, full of cafés, a whole foods shop, library branch, and mystery book shop. And it has fewer hills! We love it.

While here, we have been watching how the US economy is going. The unemployment rate is a high 9.5% across the USA (9.4% in San Francisco; 12.3% in California; and ranging from 3.6% in North Dakota to 14.3% in Nevada), with suggestions that the recovery in employment has slowed. The federal budget deficit for 2011 is estimated to be $1.34 trillion, 9.1 percent of gross domestic product. Key debates are focused on how to keep the economy going without increasing the deficit further. At the state level, California’s budget is three months overdue. As a result, staff have had to have unpaid leave and the state is now stopping payments to school districts and counties for welfare; the districts and counties will have to borrow to keep things going.

Health reform is a big issue here of course. The Affordable Care Act (dubbed ‘Obama Care’) passed in March, with some key changes in policies occurring over the next little while, and more major reforms coming later, through to 2014. Overall, the reforms are aimed at making insurance companies more accountable, lowering health care costs, increasing choice, enhancing quality of care, reducing disparities and securing the Medicare programme (for the over 65s).

Initial changes already taking place, or coming up, focus on gaps in who and what is covered. For example, young people can now stay on a parent’s plan till they turn 26; a pre-existing condition plan is now available to those who cannot get coverage because of pre-existing conditions; tax credits are available to help smaller businesses provide insurance; and free preventive care is to be provided by health insurance plans soon. There is also new funding to support public health and prevention, new community clinics and the training of new primary health care doctors and nurses.

Later changes will alter the ways in which the insurance markets work, with greater regulation of those markets, including preventing lifetime and annual limits, regulating how much plans must spend on health care services as a proportion of their premium income, and banning discrimination based on pre-existing conditions. A new insurance exchange where people not able to otherwise get insurance will be established, and everyone who can afford it will be expected to be insured, or pay a penalty. The reforms will also provide incentives for improved co-ordination of care and paying physicians based on value rather than volume.

The reforms are expected to reduce the number of people who are uninsured from 57 million projected under the previous law to 23 million by 2019. However, the reforms are still the subject of lawsuits, including one from some states arguing that forcing people to have health insurance or pay a penalty is unconstitutional. Moreover, the implementation timeframe is long, meaning a consolidated effort will be needed to ensure the reforms occur.

We have also done a bit of travelling. We spent some time in Yosemite National Park. Granite Point was particularly spectacular – you look down to the Valley way below and over to huge granite rocks (including Half Dome, picture right). Near Granite Point I watched a bear charge out of the woods and across the road, which was very exciting. We clambered up Sentinel Rock at over 8,000 feet, standing high above everything else, to look down at the green Valley 4,000 feet below us. Vista Point at Yosemite Valley was also gorgeous with a stunning view along the pine tree lined valley, with the huge granite rocks rising high into the sky. Yosemite Valley itself was packed with summer visitors and cars, and it was very hot; not the best time of year to visit!

We have also been to Denver for a conference. Denver has a modern downtown centre and excellent tree-lined mall. There are old painted pianos scattered throughout the mall that passers-by play (well!) during the day. But the best bits of Colorado were Red Rocks Amphitheatre – gorgeous red rock outcrops turned into an amphitheatre for concerts, the most famous being U2’s ‘Under a blood red sky’ concert; Dinosaur Ridge with dinosaur fossils we could touch; and the lovely Rocky Mountains, with excellent bush walks and stunning scenery, where we also saw a moose, a bear and deer.

Nearer to San Francisco, we’ve visited the lovely Muir Woods, with the tallest trees in the world (coastal redwoods). Likewise, we went to Point Reyes National Seashore, which is a great place to get away to, with rolling hills, white cliffs and lovely Pacific Ocean views, and a drive along the San Andreas Faultline.
I’ll write more a bit later in the year and keep you all up to speed with what is happening with health reform and about some of the health services research going on here. Meantime, I hope everyone is well and keeping up their good work in health services research!

Best wishes, Jackie

Information on US Health Reforms:
Details of the reforms are at http://www.healthcare.gov/law/introduction/index.html

Coverage and cost estimates are at: http://www.cms.gov/ActuarialStudies/Downloads/PPACA_2010-04-22.pdf

Analyses of reform proposals at: www.cnwf.org and http://www.healthaffairs.org/