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/