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Hundreds of people gathered for a funeral among makeshift gravestones buried in the lawn of City Hall on Dec. 11. The tombstones marked some of the essential public health and community services laid to rest by mid-year budget cuts: health care for jail inmates, day services for the homeless, the SRO Collaborative, and the Laguna Honda adult day care center.
Collectively they amount to a $36 million thinning of an already stretched social safety net that is designed to catch the most vulnerable populations in San Francisco. Of the city's $118 million projected deficit, about 30 percent will be recovered from the Department of Public Health, with cuts to care and counseling for the mentally ill, services for the elderly, and closing some medical respite housing. All these services and more have been suggested by the DPH in response to Mayor Gavin Newsom's request for deep budget cuts.
But advocates and front-line workers say these cuts will only create a greater cost to the city over time, as people with acute illnesses and mental health and substance abuse problems lose their primary care and end up in the emergency room, potentially in worse condition, receiving more costly care.
"The cuts in services are going to cost," Marykate Connor, director of Caduceus Outreach Services, said at the rally. Cuts to nonprofit organizations that handle much of the city's drop-in health services mean more ill people will end up at SF General.
But the city's premier and only public hospital is already crunched. "It's sort of crazy right now. Six to eight months from now if these cuts go through, it will get a lot crazier," said Ed Kinchley, an emergency room social worker.
In a memo to the Health Commission, DPH director Mitch Katz pointed to a higher-than-budgeted census at SF General, which provided a short-term boost in revenue but also stretched resources at the busy hospital and exacerbated its budget situation.
Kinchley, who's been at General for 24 years (12 of them as a social worker), said part of his job is getting substance abusers and people with mental health out of the ER and into care programs. "It's already hard for me to get someone in detox in a day," he said.
On a typical Friday afternoon, he's successful with one in five people. Unfortunately, when someone comes in asking for detox is the time when it can do the most good, if it's available. "It's really crucial in that situation to seize the time," Kinchley said. Though they try to keep in touch with clients and get them in as beds become available, there's high attrition on the waiting list. "They don't have a hell of a lot of choices except to start drinking again that day."
Martha Hawthorne has spent 23 years as a public health nurse for DPH, working out of the Castro Mission clinic. She does targeted case management for high-risk mothers and their newborn babies essentially making sure they're connected with other health care workers who specialize in chronic problems such as diabetes, hypertension, and substance abuse. "I'm one of the people that sees the system from the patient's point of view," she said.
She's also able to illuminate how certain cuts can have spillover effects on a newborn baby. "There are five to six specialized, highly skilled RNs being eliminated. One is an expert in diabetes care for pregnant women," Hawthorne explained. If that nurse is cut, "the clinic will still exist, the patient will have five to 10 minutes with the doctor and receive instructions, but there will be very few people to teach her how to use insulin, to follow the instructions, to change her diet.... A woman without this care can have very sick babies. This is one little, little example of a staff cutback that has a direct effect on care."
Furthermore, the way the cuts are being exacted carves deeper into the social safety net than ever before. For example, Progress Foundation contracts with the city to do acute diversion and transitional housing and services for mentally ill people coming out of General's emergency room. Its annual budget is roughly $14.8 million, mostly funded by Medi-Cal with matching state monies. A smaller amount of city money fills the gaps.
DPH has asked Progress, as well as many other nonprofit providers, for a 5 percent cut but the cut is based on the entire foundation's funding, not just what the city gives them. Executive director Steve Fields said that means closing two out of three acute diversion programs or four out of six transitional residential treatment programs.
"It ends up closing about $3 million in programs to save $700,000 [of city money] over the next 12 months," Fields said. "I'm sympathetic to the problem, but it just doesn't make sense to give up that much [state and federal] money." He pointed out this represents 40 to 50 transitional beds or 20 acute diversion beds in facilities that have been licensed, permitted, received neighborhood approval, and have been functioning at 90 to 95 percent capacity. "Once you lose these beds, you don't get them back."
And, he said, the real effects are felt on their clients. "However you look at it, the need will be there. They don't leave town. We end up seeing them somewhere. They're going to be in a hospital bed or they're going to be in jail or they're going to be in a longer-term skilled nursing facility" all more expensive solutions to a chronic problem. "We may be making decisions that we may regret down the road because we've had to react so immediately to the crisis," Fields said.
"This is happening at a time when there's all this increased need," said Jennifer Friedenbach, executive director of the Coalition on Homelessness.
The numbers for families, provided by Compass Community Services, are grim: between 2007 and 2008, the number of families seeking shelter jumped from 75 to 148. At the same time, the city has reduced family shelter beds by 20 percent, and the waiting list is now more than four months long meaning families are waiting for shelter longer than they can actually stay in it.
"It's a really brutal time to cut health and human services," said Friedenbach, whose group is advocating for an alternative list of cuts that incorporate some of the suggestions posed by SEIU and the Coalition to Save Public Health. They call for capping city salaries at $150,000 and letting go of all management staff brought in since a 2007 hiring freeze.
Hawthorne pointed out that while these cuts hit the neediest hardest, public health for everyone will suffer, pointing out that the city will be less prepared for a large-scale emergency or epidemic.
"SF General is a trauma center, and anybody who needs top-level trauma care is going to end up there. If it's crowded with people who don't need that level of trauma care, their response will be slower," said Hawthorne, adding that all emergency rooms in public and private hospitals are ultimately affected by cuts to clinics and nonprofit services.
"On a hopeful note, there's huge potential as people realize the depth of these cuts," Hawthorne said. "The public needs to demand the human right to health care."