Click here to listen to Wilburn talk about the violence in the streets that drove him to seek a better life with treatment from St. Anthony.

St. Anthony’s, a free clinic in San Francisco, caught a glimpse of the future of health care a few years ago. The sidewalks around the clinic, which is in the city’s tough Tenderloin neighborhood, are full of people looking for something they need: some want a meal in St. Anthony’s dining hall or a place to spend the night. Others are looking to score their next fix from a street-corner dealer.

The clinic has a long history, one that reveals decades of challenges in providing health care for the poor people who line up for the clinic’s help – challenges that likely won’t end when federal health care reform takes full effect in 2014.

St. Anthony’s medical clinic opened in the 1950s, when a San Francisco General doctor, Francis Curry, noticed that tuberculosis was starting to creep through the Tenderloin district. The St. Anthony Foundation already helped the poor through social service programs in the neighborhood. Dr. Curry — who would later become Director of Public Health for San Francisco – started screening people for the disease in the dining room, and the clinic was born.

St. Anthony’s provided health care for free for years. At first, the Catholic institution didn’t accept any funding from the government, even as the services expanded over the years. They got help from doctors and nurses at nearby St. Joseph’s Hospital, who volunteered their time to help the poor and sick.

But then St. Joseph’s folded in 1979. The medical clinic grew again to make up for the loss of the hospital. The neighborhood changed around that time too. They once served mostly poor single men, but more families started emigrating to the Tenderloin in the 1980s, mostly from Southeast Asia. They added pediatric care and rethought their mandate to operate as a free clinic.

If a client became eligible for Medi-Cal or Medicare, they’d have to find a new medical home. Families with different levels of eligibility couldn’t all attend the clinic. Private donations and bequests grew smaller and came less often.

Sticking with the free system didn’t seem right anymore, says St Anthony’s Medical Director Ana Valdés.

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Click to hear John Frank, a St. Anthony’s patient with diabetes, talk about how the devotion of the staff to improving his condition helped him take charge of his illness.

Valdés dedicated her career to serving the underserved after becoming frustrated with the focus on the financial bottom line at private practices. She wanted to use her cultural background – she is Vietnamese and Mexican – to provide better care to the underserved when she came to the clinic in 1998.

Part of improving care was changing how the clinic was funded. After more than 50 years as a free clinic, in 2010 the clinic decided to accept insurance, Medi-Cal and Medicare. “It didn’t make sense to deny them care because of something that was now a right,” Valdés says.

It took nearly a year and a half for them to get a system in place to accept payments. Almost simultaneously, health care reform was enacted.

The foundation still feeds the poor in their dining room, now serving more than 3,000 people each day. But how they provide health care is, already, much different from their grassroots beginnings.

They began accepting insurance by joining the city’s health benefits program—Healthy San Francisco. That was the beginning of a huge cultural shift. Once, they treated any patient who showed up and said they were uninsured. Today they begin care by determining patients’ eligibility for safety net programs.

“Now you have to bring ID and go through an eligibility process,” Valdés says.

The process has brought new challenges to the clinic, she adds. And while they hope their new funding sources will make the clinic sustainable, there’s no guarantee it will.

“You think it’s dysfunctional when you’re free, because you’re trying to access all these things,” she says. “But then you get in it and it’s like: Wow! It’s just as bad on this side.”

Right now the clinic is paid a per-patient Medi-Cal rate for enrolled clients. Valdes wouldn’t say how much, but did say that it covers about 10 percent of the cost of serving patients. “Maybe, if you’re lucky, it’s a quarter of your cost.”

They are still figuring out ways to cover the majority of their operating costs. One option would be to apply to become a federally qualified health center. At the end of the year the federal government makes up the difference in cost between reimbursement and actual expenses for those clinics.

St. Anthony’s is also trying to operate more efficiently and to keep their patients healthier to avoid costlier procedures, in line with health care reform. But they aren’t reimbursed for these programs, Valdés says. Changes to the fee for service model, where the clinic is reimbursed based on how many patients they see, may be needed to make health care for the poor a sustainable proposition for clinics.

“We’ve got to be careful because if we don’t reimburse people at a rate that’s sustainable,” Valdés says, “then we’re going to see a lot of small clinics and community health centers suffer or close because they won’t be able to maintain the reporting or the infrastructure that they need.”

“The health-care world is frankly a little schizophrenic right now,” she added.

Community clinics like St. Anthony’s are at the cutting edge of medical care in some ways: the need to stretch their budget has also made them innovative. For instance, they developed a diabetes program in 2002, noting that the Tenderloin had one of the highest rates of diabetes in the city, just as their founder Dr. Curry had noticed the high level of tuberculosis.

A grant from the Kaiser Permanente Foundation let them bring in a nurse to set up a unique diabetes management program. Instead of waiting for people to come in already sick from diabetes, they reach out to clients to make sure they are taking care of themselves.

Such programs make a difference to people like John Frank. The 57-year-old came to St. Anthony’s three years ago when he could no longer work because of complications from diabetes. He suffers from painful swelling in his feet and is losing his eyesight. But the most difficult complication for him to manage is his depression. He’s been able to get the medical attention he needs at the clinic as well as weekly sessions with a mental health counselor.

He attends the clinic’s yearly diabetes day event to learn more about lifestyle changes he can make, like cooking more healthful meals. Frank, who sold athletic supplies when he was working, would also like to help the clinic set up an exercise program for other diabetes patients.

“The truth, is we used to be free, so we are very creative about finding resources for our patients,” Valdés says.

The connection between mind and body is one example of the clinic’s up-to-date approaches. As part of the larger human services network of the St. Anthony Foundation, since their founding, they understand the multifaceted needs of their clients.

The network also brings patients to their doors. Patients like 59-year-old Otis Wilburn who was initially introduced to the clinic in 2005 through St. Anthony’s year-long residential drug treatment program. Each patient who enrolls in the program is first screened at the clinic.

After a lifetime of drug use, Wilburn came to the clinic with many health problems. He had heart and lung disease, prostate cancer and now has seizures in his sleep. He takes six pills every morning to stay on top of his health problems. He’s been clean and sober for the last three years.

Valdés thinks it will be difficult for their patients who suffer from mental illness and substance abuse to navigate the new process, afford insurance and stay enrolled. And about 60 percent of their more than 3,000 patients, she adds, won’t qualify for health-care insurance under the Affordable Care Act because of citizenship status.

“Even though in theory everyone would be insured with health-care reform, we know that’s not true,” Valdés says.

So St. Anthony’s will continue to serve the uninsured of the Tenderloin.

After all the changes, Valdés has moments when she finds herself wishing she could return to the simpler world of free clinics.

“I think I’d be lying if I said there were no regrets,” Valdés says. But, she adds, “overall, I think it was the right way to go.”