Now that last week's health care vote has put behind us the phony fretting about death panels, federally funded abortion holocausts, and socialist takeovers, it's time for legitimate worrying about reform to begin.

"Could health care bill lead to local doctor shortage?" KGTV Channel 10 News in San Diego asked on March 23. "Regional health care providers concerned about meeting increased needs," a headline read in the Morning Call in Allentown, Pa., the same day. "There is already a shortage. I think there are going to be some areas of the country that are going to notice a pressure on their system," said Michigan State University Osteopathic Medical School Dean William Strampel, quoted by WLNS TV news in Lansing.

Indeed, it's reasonable to imagine that offering to cover 32 million uninsured people might exacerbate a situation where "we're not accepting new patients" is already the most common phrase in U.S. medicine.

For a view of the unintended consequences of providing coverage to a larger number of Americans, it's helpful to look to San Francisco, where, as of December, 50,000 locals had signed up for a program in which the uninsured can turn to private nonprofit and government-run clinics for care. Called Healthy San Francisco, it's a version of universal health care that, along with a health care overhaul in Massachusetts in 2006, has been billed as a model for national reform.

A recent study says Healthy San Francisco patients have been happy with their subsidized care. But statistics compiled by the city controller suggest that services for those already receiving public care may have deteriorated just as the program was adding patients.

During 2009, when more than 15,000 new patients enrolled in the program, average new patient wait time for an appointment at a Department of Public Health primary care clinic increased from 18 days to 29 days. Public clinics, along with certain private clinics, serve as entry points to the Healthy San Francisco program.

Consider the recent experience of enrollee Jennifer Ranft, 33, who has worked as a server and bartender, and is now employed by the Coalition on Homelessness. She went to pick up medication at the South of Market Health Center, a nonprofit clinic affiliated with Healthy San Francisco, where her primary doctor works.

"There were 30 chairs, and almost all of them were filled, with two people standing up," she said. "And the receptionist had two people in front of her trying to check in."

The increased wait has been caused by several factors, said Healthy San Francisco director Tangerine Brigham. Two clinics in Chinatown and Potrero Hill are undergoing renovations to increase capacity to meet demand. Additionally, the increased unemployment accompanying the current recession has driven people to public clinics. "We've seen many more people coming in with children," she said. "More people are now eligible for Medicaid because of what's happened to the economy."

But it's also true that, despite preparations for new Healthy San Francisco patients, the city's subsidized health care has been stretched by the influx — just as America's short-staffed health care system will soon become even more clogged.

"It wouldn't surprise me if you have some shortages of doctors, and longer wait times," said Dean Baker, codirector of the Center for Economic Policy and Research in Washington, D.C., a liberal think tank. "The question is how much do we expand enrollments in medical schools? How much do we increase the number of foreign doctors we allow in the country?"


Among people signing up for Healthy San Francisco, who as a group tend to be sicker and older than the general population, the program has been well received, according to an August 2009 Kaiser Family Foundation study. "Participants in Healthy San Francisco report high levels of satisfaction and voice a resounding endorsement for the program," the study said. "Ninety-four percent say they are satisfied with the program overall, and nine in ten say they would recommend the program to a friend."

But this enthusiastic thumbs-up shouldn't be construed as endorsing a reinvention of local health care. Rather, it was a measure of what lower-middle-class people feel when they're extended the same services already available to the indigent. The Kaiser study took no measure of how people felt about the fact that waits for appointments had grown by 60 percent in a year.

Even if it had, the study may have found that long waits to see doctors have become — like long commutes and cramped airline seats — a commonplace modern nuisance people no longer complain about.

In fact, Ranft had nothing but good things to say about the medical care she receives through Healthy San Francisco. "The doctors are wonderful," she said. "I have no complaints about the doctors. What can they do if you have so many people, and you have to give attention to all of them?"

Under Healthy San Francisco, every uninsured resident aged 18 to 64 can get services, regardless of citizenship, employment, or ailment. Individuals with incomes up to $54,150 (or $110,250 for a family of four) pick one of several government or private clinics as a portal into city health services. But those patients enter a system whose resources are getting thinner. According to Jennifer Friedenbach, executive director of the Coalition on Homelessness, patients who received public care would have had to endure longer waits irrespective of Healthy San Francisco, thanks to budget cuts in recent years. "What they did do was cut health care. They got rid of a bunch of clerks and other workers," she said. "We know that was leading to longer waits."

Brigham says the city didn't just jam the existing system with tens of thousands of less impoverished new patients. For one thing, 75 percent of Healthy San Francisco beneficiaries were already receiving some sort of publicly subsidized health care, including services from existing programs such as Medicaid, Healthy Kids, Healthy Workers, and Healthy Families.

This means Healthy San Francisco wasn't as ambitious as it may seem at first glance; only about 12,500 enrollees are new to the public health care system, and the rest were merely re-enrolled in a program with a new name. What's more, the city has added $36 million to existing program funding in order to accommodate new Healthy San Francisco patients. This has meant spending more than $8 million on additional staff, more than $5 million in reimbursements to UCSF Medical Center for patient care, and $7 million to other outside medical providers.

"We knew that, in order to do this program effectively, we had to expand capacity internally and externally, and we've been purposeful in using those additional dollars to do both," Brigham said. Most Healthy San Francisco enrollees have used their new benefits to obtain services that were once available only to those receiving other forms of public health care. Now, San Francisco's indigent care system has had to make room for middle-class people.

"I guess I wouldn't call it 'stretched,'" Brigham said. "We've expanded the system to accommodate new individuals who've selected the Department of Public Health as their medical home."

Providing basic health care to more people doesn't just translate into longer lines; Brigham said it produces corollary benefits for everyone. Healthy San Francisco patients "use services more efficiently. They're not using emergency rooms for conditions that are avoidable. You've been able to see reduction in emergency room visits and the like." Additionally, Brigham said, average wait times should go down as construction is completed at the public clinics in Chinatown and Potrero Hill.

Expanding access to health care is a good thing, in spite of the unexpected consequences. But if America's solution produces millions more insured patients without dramatically increasing the number of doctors, nurses, and hospitals available to serve them, the rest of the nation might begin to see a situation similar to San Francisco's.

"I think [San Francisco has] done a good job of extending coverage," said Baker of the Center for Economic and Policy Research. "But you're going to have to do some repairs on that. You don't want people to wait for needed care."

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