More than a year after taking the helm of the San Francisco Department of Public Health, Barbara Garcia, the agency's director, expressed optimism about the city's future under the national Affordable Care Act and also spoke of keeping an eye on the city's numerous LGBT health-related nonprofits.

In a wide-ranging interview last week, Garcia sounded confident in how the city will fare under the national health care reform law, which was designed to cover more uninsured people and which the U.S. Supreme Court upheld last month.

She said the Healthy San Francisco program, the city's health insurance program for uninsured residents, "put us way ahead," since "we already know who our uninsured are" and officials have worked to provide them with "medical homes."

"Clients should see a seamless system of care," Garcia, an out lesbian, said.

Garcia said she also wants to see more long-term planning.

When it comes to HIV/AIDS prevention, "San Francisco has always been on the leading edge." However, since the epidemic affects virtually every state in the country, the city, known as a model of HIV care and prevention, "will continue to see a reduction" in federal funding, she said.

Earlier this year, Mayor Ed Lee said he would restore millions of dollars that were being lost in federal HIV/AIDS funds, including a reduced share of the Ryan White HIV/AIDS Treatment Modernization Act. The federal cuts hit in the fiscal year that began in July. Garcia noted there's still a shortfall for 2013-14.

Garcia, whose agency's budget is about $1.6 billion and whose annual salary is $259,000, met with the Bay Area Reporter on Thursday, July 19 at the health department's Grove Street headquarters.

Among some of the work being done to prepare for the future, she discussed the city's HIV Health Services and HIV Prevention Planning councils having joint planning meetings.

In a follow-up email exchange, Garcia said, "The panels are not merging as yet, but that is not off the table." She added, "I hope, through joint meetings and planning processes, to ensure that we are preparing for the future of potential reductions and health care reform."

Last week, the B.A.R. reported that out Supervisor Scott Wiener and transgender leaders announced that the city would be removing transgender exclusions in the Healthy San Francisco program. The Health Commission is expected to vote on the issue soon, which would remove the exclusions, although Garcia said it would take another year to year and a half to implement the changes.

In the interview, Garcia explained that requests for proposals and contracts would have to go out to Healthy SF providers.

Sexual reassignment services, treatment, and surgery would be covered for transgender patients once the changes are implemented. Hormone services are already provided through the city's Tom Waddell Health Center.

 

Affordable Care Act

Whatever improvements the ACA brings, not everyone will be included by the federal government. Undocumented people are among those who aren't set to be included under the new national law.

But the health department "has always made a commitment" to serving undocumented people, Garcia said, adding that "HIV doesn't see a difference" between people based on whether they have documentation; they are included in Healthy SF.

Last Monday, July 16, the U.S. Food and Drug Administration announced the approval of Truvada, a once-daily combination made by Gilead Sciences, for pre-exposure prophylaxis – better known as PrEP – to prevent sexual transmission of HIV.

The National Institute of Allergy and Infectious Diseases is working with local public health departments to develop demonstration projects that will attempt to answer some of the outstanding questions about PrEP.

The first two programs – in San Francisco and Miami – are expected to start in late August, according to Stephanie Cohen, medical director at City Clinic, which will spearhead the local project.

Garcia said officials are "just beginning" their work on the pilot.

Portions of the ACA have already gone into effect, like parents being able to keep their adult children on their policy until age 26. Others, including the controversial individual mandate, which requires people to obtain health insurance or pay a penalty, are scheduled to go into effect in 2014.

 

Monitoring nonprofits

The health department pours millions of dollars into the city's numerous nonprofits. One annual ritual is for many of the organizations to cry out for money, as elected officials scramble to cover shortfalls.

"When we go south, they go south," Garcia said of the public funding on which many organizations rely.

Local nonprofits have sometimes appeared to be the victims of their own financial mismanagement and other problems, at least as much as they've been hurt by dwindling public resources.

Signs that an agency is in trouble may include the departure of the executive director, "inner conflicts" among board members, and the organization not being able to meet payroll, Garcia said. She said some agencies have been put on a "corrective action plan," but nobody's currently "at that level."

She hopes that she and others "can come up with some cost-saving measures," she said.

Garcia spoke about pooling "back office" resources for agencies, which could mean multiple organizations sharing administrative and other resources.

Agencies with budgets of $5 million and under are the ones being targeted. Garcia said the process will be "long term" and an advisory group will be involved.

She also said she'd like to see a more manageable array of nonprofits in the city, and merging some organizations is an option.

However, she said, "I can't force these mergers. They're separate agencies," and often act as "sovereign nations." Additionally, many of the nonprofits reach populations that "we could never reach," she said.

"You want that diversity, but you also want them to comply with what they need to get done," Garcia said. "... I have to be responsible for the public dollar."

One organization that required much of Garcia's attention recently was Tenderloin Health, which served some of the city's poorest residents, including people living with HIV and AIDS. The agency shut down in April after years of struggling.

Tenderloin Health had long been "a very unstable organization," Garcia said, and she'd spent "a lot of time" with the agency's leadership. However, she said the nonprofit has been "pretty close" to turning around until it learned it was losing more than $500,000 in federal funding.

Garcia bristled at questions about why she hadn't said more publicly about Tenderloin Health's troubles before it shut down.

"Why would I do that?" she said. "My job was to try to stabilize" the agency, which she noted served some of the city's "most vulnerable" people.

Many clients who had received care through Tenderloin Health were transferred to Asian and Pacific Islander Wellness Center, another locally based nonprofit.

In response to an emailed request for comment on Garcia, APIWC Executive Director Lance Toma said she "holds such a high commitment to ensuring that client care is always driving her decisions. It has been inspiring to work with her and to be a partner to strengthen the safety net in the Tenderloin. San Francisco is in good hands under Barbara's direction."