Sarah Gordon, the executive director of Clinic By The Bay, a nonprofit helping uninsured adults, discusses the challenges facing those without health insurance.

Demystifying Data

Demystifying Data is a recurring series examining the numbers and statistics that buzz around the Bay Area. The Bay City News Foundation brings context and expert input to the data in our everyday lives. We will bring your questions to those who know best to understand the big picture behind complex figures. Check back weekly for new numbers, broken down by the experts.

Nearly 3.2 million Californians have no health insurance.

In 2022, nearly 10% of California’s population under the age of 65 remains uninsured. The University of  California at Berkeley Labor Center and University of California Los Angeles Center for Health Policy Research reported jointly that nearly 3.2 million Californians have no health insurance.

Programs like Medi-Cal, which aims to bring health insurance to low-income Californians, and the Affordable Care Act, which brought about more affordable coverage federally, still have gaps with millions of residents falling through.

Enrollment in reduced-cost or free insurance programs in the state leave out those who still struggle to afford coverage but may not meet the requirements, whether it comes to income or citizenship status, said Sarah Gordon, the executive director of Clinic By The Bay. Gordon said undocumented and documented immigrants make up a large part of the uninsured population of California.

Clinic By The Bay, located near Balboa Park in San Francisco, serves uninsured adults in San Francisco and San Mateo counties with free health care. The clinic, which is privately funded, aims to provide comprehensive care to those who cannot afford it for any reason.

This week, Bay City News Foundation hosted Gordon to discuss the work being done at Clinic By The Bay and shed light on the challenges uninsured Bay Area residents face. Gordon discussed how lack of health insurance can affect someone’s life and broader society, how all Californians are affected and what might fill in the gaps of existing laws.

Gordon’s answers may have been edited for brevity and clarity.

Sarah Gordon, the executive director at Clinic by the Bay, spoke with Bay City News about the uninsured population in California. (Sarah Gordon)

Q: How did you get involved in working with uninsured residents of San Francisco and the broader Bay Area?

A: I was born and raised in San Francisco, and fifth generation on my mom’s side. The city is in my blood. My background is in public health. I graduated from SF State with a community-based public health degree. I’ve always had a passion for social justice issues, access to health care being the predominant one.

After graduating from SF State, I went off to work at the San Francisco Community Clinic Consortium. They are a network of community health centers and FQHCs [Federally Qualified Health Centers] in the city. I worked with them for about nine years. I worked in policy for a little bit, and then I managed their AmeriCorps program. It’s like the National Peace Corps, but this was a health-focused program. I worked with a bunch of students who were mostly doing a gap year in between applying for medical school. I placed them in community clinics across the city and managed their placements and training opportunities and all of that. They did a year of service in community health centers in the hopes that they would go off to become primary care providers working with underserved populations, which a lot of them have done. It was definitely an awesome health care workforce program and workforce development program. Then that program lost funding because the [federal government] cut funding for it.

After that, I got recruited by one of those FQHCs in the Tenderloin. It was through HealthRIGHT 360. They are a large network of clinics in the city. I was the director of operations at their Tenderloin clinic for three years before that clinic closed. That was in October of 2019, and then I took a little bit of time off, because I was just a little bit burnt out from managing a clinic in the Tenderloin for three years.

Then the opportunity came about at Clinic By The Bay. I started with Clinic By The Bay in June of 2020, right at the beginning of the pandemic. It was definitely an interesting transition and shift, but it’s a very different kind of clinic, being that we are privately funded, don’t accept insurance and are volunteer-powered. It was definitely a nice shift. It feels a lot like community medicine. Everyone’s really engaged and involved, and we can take lots of time with our patients.

My last clinic was really productivity focused. We were churning and burning patients, bringing them in and getting in as many 15-minute visits as possible and sending them on their way. These were very high-need patients that were very, very sick, many with mental health issues and substance abuse issues.

So, it’s been really nice at Clinic By The Bay because we can do things the way we want to and take as much time as we need to make sure we’re developing programs and services that really, really help support our patients. I love it, and it’s been two years now.

Q: The estimate of uninsured Californians is just under 3.2 million. As someone working with these individuals at Clinic By The Bay and for all of your career, how does it feel to hear such a figure?

A: It makes me really angry, and just pissed off at our system. I really feel that health care is a right; it shouldn’t be something that is a privilege for people that can afford it or have the means to access it. 

I’ve worked with uninsured or underinsured or just low-income individuals pretty much my whole career. They get the short end of the stick and kind of everything in life. It’s hard to access most things, and the fact that you have an issue accessing the means to keep yourself healthy and be a productive member of society is really frustrating.

I think if we invest in our people by making sure people can lead healthy, productive lives, it is better for everyone and it’s better for society as a whole. We all thrive.

Those numbers just frustrate me, and I wish there was more being done systematically and nationally to address it and get more people access to health coverage.

Q: When your patients come to Clinic By The Bay for the first time, what problems are they facing due to their lack of health insurance?

A: For us, at least with our patient population, it’s really exacerbated chronic disease issues. Someone who is diabetic, could be managing if they had health insurance coverage or if they had better access to resources, like medications, nutritious food or lifestyle changes and someone to support them through that. Their health outcomes could be better, and their chronic disease wouldn’t be so far gone, to the point where they’re really experiencing some severe health issues.

This is more of an example from my last clinic, not my current clinic, but we had a patient whose diabetes was so far gone that he had to have his leg amputated. Being a primary and preventive health care clinic, it’s like a river and if you can catch it upstream, they’re not going to fall down the waterfall at the end of the river. That’s really what primary care is; if you can help manage the disease early on, it won’t get so far gone, where you end up needing your leg amputated, or something like that.

That really is what we see, since a lot of our patients haven’t ever had any health insurance coverage. Most of our patients are immigrants and don’t qualify for Medi-Cal. So, they don’t do anything about their health issues. They just kind of hope for the best and, by the time they get to us, and they make it in our doors, they haven’t seen a doctor in five or 10 years and their health issues are pretty severe. So, we have to do a lot of work to get them to a healthy stable place.

That is typically what we see with our patients. By the time they get to us, it’s exacerbated chronic disease. Most of our patients are suffering from diabetes, hypertension, high cholesterol and things like that, that could be managed if they had received care earlier on.

Q: I know you mentioned the benefits that come with regular preventative health care on the individual level. Are there ways that routine care for uninsured people can benefit society more generally?

A: Well, it’s cheaper for society as a whole. I mean, honestly, if you look at kind of the cost of health care and the cost of preventive services, like routine checkups and labs and even social supports and things like that, versus emergency services or surgeries or high-cost medications and things like that, there’s an extreme variance in the cost to society as a whole.

And we as taxpayers are paying those bills. If they don’t have access to primary care, they’re going to end up in the emergency room for something that could be prevented through regular routine doctor visits. Then it’s a super high cost to care for that patient in the emergency room. And if that individual doesn’t have health insurance, that’s government funded, so the government is covering the cost to care for that patient.

So, you know, it’s not just about having more healthy and productive members of society, which benefits all of us, but the cost associated with taking care of more sick and more ill and more severe health issues for people costs a lot more for us. So, as Californians, we’re paying the price, whether we think we are or not.

Q: What is the experience for someone without health insurance like in going to Clinic By The Bay for the first time?

A: A lot of our patients hear about us by word of mouth, because a lot of our patients are immigrants, and they might be distrusting of systems and larger entities. We establish a lot of trust with our patients, and then they share that with their family and their friends.

A lot of times, people will either call or show up, just saying that they don’t have health insurance. And that’s one of our requirements. To be a patient of Clinic By The Bay we verify that you’re over 18, and that’s intentional that we don’t cover children, because all children are covered in California. We’re really trying to fill a gap and an unmet need for the community, so only adults are covered as long as you’re uninsured.

We don’t care why you’re uninsured, you can either not qualify, or maybe you do qualify, but you just can’t afford it or you’re working a low wage job or you don’t have employer-sponsored health coverage. Maybe you don’t qualify for free Medi-Cal or subsidized Medi-Cal, and you just can’t afford to pay out of pocket and take care of yourself and your family. So, as long as they don’t have health insurance and they’re over 18 and they make under 500% of the federal poverty line.

We do an eligibility appointment. If they’re interested in being a patient, we set them up for an eligibility appointment. And that’s where we kind of verify everything. We verify that they live or work in San Francisco or San Mateo County, that they’re over 18 years old and that they make under 500% of the federal poverty level.

We do all their intake paperwork and then we set them up for their first visit with a provider, which typically we can get somebody in within about two weeks to see a doctor for the first time.

The patient experience is stellar compared to a lot of other places that I’ve worked with. We take our time. Our typical visits are 30 minutes to an hour, as opposed to 15-minute visits that you get, even with commercial insurance. We’re all consumers of health care ourselves, and I have Kaiser and my visits are pretty darn quick. So, our patients really love it.

We take the time needed to really make sure we’re addressing all their health concerns. We have programs that support everything else that they might need to manage their care. We get them on prescription assistance programs, and we have a free pharmacy, so we can dispense donated medications for free. We do health coaching, so we can have one-on-one visits with a health coach to talk about their diabetes, their diet or nutrition or exercise and help them make some lifestyle changes. We also have a food pharmacy and a food-as-medicine program. We can get people linked-in with healthy staples to supplement their nutrition needs. We can link them to outside services or any other specialties that we have within the clinic, if they need dermatology or physical therapy or things like that, that we can do in the clinic, otherwise we refer them out.

So, they get really well coordinated care. Our patients really, really love it. And sometimes our patients will start with Clinic By The Bay and they’ll get health insurance, and then they won’t want to leave. We’ve had that happen with a couple of our patients where they start having employer-sponsored health coverage and they love it so much at Clinic By The Bay that they don’t want to go find another clinic. We try to help them navigate that and make sure that they’ve landed at another clinic before we stop seeing them.

Q: How many patients do you currently serve at your San Francisco office space?

A: We currently have a little bit under 1,000 active patients, and we’re pretty limited. We’re currently in the middle of a capital campaign to move into a new building that’s right around the corner from our current location. That’s going to give us the opportunity to really expand to reach more people.

I mean, we’re really limited by our lease to only be able to see patients twice a week. Once we move the whole space will be ours. We can see patients five days a week, and we are adding dental when we move. So, we’re building out a two-chair dental suite, which we know is also a huge need for the community. Dental coverage is so very separate from medical coverage, which is crazy.

Hopefully by the end of the first quarter of next year, we’ll be moving into our new space, and we can really expand our reach and serve a lot more people and add programs and services. We’re looking forward to that.

Q: While there are programs to bring health insurance to more Californians, millions are falling through the cracks, with places like Clinic By The Bay trying to fill in the gaps. How does that happen?

A: Oh, my gosh. I wish I knew the answer to that question. You know, I don’t know. I think that’s a lawmaker policy question for why certain groups of people have historically been excluded from programs.

There are programs out there that are there to serve the poorest of the poor, like Medi-Cal, for example. If you may have no income, you automatically qualify. I don’t know the reasons behind leaving undocumented individuals out of that, but I think that’s a historical racial issue that’s not just happening in California, I’m sure.

But I know, there’s the attempts for expansions of Medi-Cal and the Affordable Care Act to try and get as many people health insurance as possible. I think those efforts are great.

But there’s always going to be people that fall through the cracks. And until there’s universal health coverage for everybody, places like Clinic By The Bay are going to still need to exist. I mean, the day that Clinic By The Bay doesn’t need to exist will be a great day, right? We are there as we’re needed. But once we’re not needed, that would be amazing. We always hope for our patients to have health insurance, and we want them to have coordinated coverage through a larger system. If I was there in Sacramento, making the laws myself, I would change it.

There are some Medi-Cal expansions on the horizon. There was a smaller one that happened back in May where they started covering undocumented immigrants over the age of 50. So that expanded a little bit, so a little bit more of our patients now qualify for Medi-Cal and we’re helping to link them. I think next year, there’s going to be more expansion of Medi-Cal where all undocumented immigrants qualify. So, we’re kind of just waiting and seeing what happens. A lot of our patients have trust issues in larger, societal systems, so I’m not sure that everybody will want to just jump on to Medi-Cal if they’re patients of ours and undocumented immigrants, but I guess we’ll see.

Q: I know you mentioned that you’ve dealt with a lot of the clinics serving the uninsured population closing, largely due to funding issues. How does working in clinics facing uphill battles to operate feel?

A: It sucks. It’s stressful. 

In my last clinic, like I said, we had these productivity expectations, churning and burning patients in and out. It led to a lot of staff burnout and provider burnout and frustration because we’re all there to help and we want people to be healthy and live healthy, productive lives. When you’ve up against the bureaucracy of getting in as many 15-minute visits as possible, it’s really frustrating. You feel like you can’t do your job to your fullest extent. So, we did have a lot of provider burnout.

[Clinics are] based on this reimbursement model. And so, you get those visits in, and then you’re billing Medi-Cal, and you’re getting paid by Medi-Cal for those services. And I think that’s where that clinic fell short. It wasn’t generating enough revenue to stay afloat.

I think with Clinic By The Bay’s model, it’s still difficult. We have to apply for grants, and we’re constantly doing campaigns and looking for donations and hosting events and things like that to get donations coming in. But we have a little bit more freedom to make money in the way we think will really support our efforts, as opposed to only getting income through insurance reimbursements.