SAN FRANCISCO MARIN MEDICINE
JOURNAL OF THE SAN FRANCISCO MARIN MEDICAL SOCIETY
Special Section: Resistance is our Rx
Our CMA President
IN THIS ISSUE
Michael Schrader, MD, PhD
10 CMA's 2025 President: Shannon Udovic-Constant, MD
Michael Schrader, MD, PhD, and Steve Heilig, MP
Jessie Mahoney, MD 7 Editorial: Resistance is Our RX
CMA House of Delegates Report: Standing Up for Health
Ameena Ahmed, MD and Steve Heilig, MPH
Protecting Physicians from Coercion by Immigration and Customs Enforcement
Michael Schrader, MD, PhD
Emergency CMA Resolution: Restoring Sound
Toni Brayer, MD, FACP
"I'm Afraid for My Patients": How Trump's Deportation Plans are Hitting California Hospitals
Theresa Cheng, MD, JD 18 Renew: Looking Back and Moving Ahead
Linda Hawes Clever, MD, FACP
In the Newest Salvo in the Soda Tax Wars, David Beats Goliath in Santa Cruz
John Maa, MD
Memo: Emphasizing the Community-wide Benefits of Protecting the Most Vulnerable as Federal Threats to Medi-Cal Loom
20 Why Traditional Physician Wellness Doesn't Work - And What Does
MEMBERSHIP MATTERS
A Message from the SFMMS President in Response to Federal Actions
Like many of you, the physician leadership and staff of the San Francisco Marin Medical Society (SFMMS) have been monitoring recent federal actions taken by the Trump administration that have potential far-reaching and detrimental effects on quality of and access to care for underserved and underrepresented populations, reproductive rights and freedoms, and gender-affirming care.
SFMMS, alongside our partners at the California Medical Association, county medical societies, community benefit organizations, and nonprofits working on health and healthcare issues, remains unwavering in its commitment to support physicians and their patients. As each federal action is announced, we will work in tandem with these partners to understand how it will affect your medical practice. Resources and updates will be shared weekly via all-member communications and in SFMMS’ quarterly journal, San Francisco Marin Medicine, and
CMA Organizes National Medical Association Coalition to Protect Access to Care
A coalition of all 50 state and the District of Colombia medical associations, representing hundreds of thousands of physicians and their 80 million Medicaid patients, have united to demand that Congress protect Medicaid from the devastating $880 billion Energy and Commerce Committee spending reduction target in the House Budget Resolution. CMA urges physicians and patients to join us in opposing these damaging cuts, and urging your members of Congress to do the same. Visit our grassroots action center to send a one-click message to your members of Congress: https://www.votervoice.net/mobile/ CMADocs/Campaigns/122041/Respond
SFMMS Update: Legal Challenges to New Federal Health Policies
SFMMS has heard from many of our members concerned about the new federal Executive Orders and policies affecting health care services, patients, researchers, and physicians. While SFMMS works with CMA, AMA, and other partners to push back on harmful policies, you can follow the latest updates on the legal cases concerning those policies here: Litigation Tracker: Legal Challenges to Trump Administration Actions. https://www.justsecurity.org/107087/tracker-litigation-legalchallenges-trump-administration/?utm_source=chatgpt.com
Are you and your patients being affected by Federal Executive Actions? SFMMS is collecting stories from our membership about how physicians and/or their patients are being affected by Federal Executive Actions. If you have stories to share and/or would like to connect with an SFMMS staff member, please email membership@sfmms.org.
on our website. You can find an initial collection of resources related to immigration issues. https://www.sfmms.org/newsevents/sfmms-blog/resources-for-physicians-health-facilitiesresponding-to-immigration-issues.aspx
Our physician leaders and volunteers, each passionate advocates for health equity and protecting the profession of medicine, are united in our mission to represent, support, and advocate for you. There are challenges ahead. We encourage you to contact us at info@sfmms.org to share how you are being affected by current and future federal actions so that this information may inform the deliberations of our Committees and Boards of Directors. We will navigate these challenges as we always have – together.
Sincerely,
Jason Nau, MD President, San Francisco Marin Medical Society
Updated Regularly: Resources for Physicians and Health Facilities Responding to Immigration Issues
In December 2024, California Attorney General Rob Bonta issued updated guidance for health care facilities summarizing relevant legal considerations and policy recommendations when responding to immigration issues. Physician practices should consider developing protocols (or reviewing and updating existing policies and procedures) for collection and retention of patient data, including patient immigration status, and for responding to immigration enforcement visits and requests for access, as well as training staff on any new protocols in advance.
SFMMS is collecting resources from our physicians members and partner organizations. If you have resources to share with your colleagues, please email membership@sfmms.org.
View SFMMS curated resources at https://www.sfmms.org/ news-events/sfmms-blog/resources-for-physicians-health-facilities-responding-to-immigration-issues.aspx
SFMMS EVENTS
To learn more about our upcoming SFMMS events and offerings, visit our SFMMS events page at https://www.sfmms.org/news-events/events or scan the QR code with your smartphone.
January/February/March 2025
Volume 98, Number 1
Editor Michael Schrader, MD, PhD
Managing Editor Steve Heilig, MPH
Production Maureen Erwin
SFMMS OFFICERS
President Jason Nau, MD , MD, DDS
President-Elect Sarita Satpathy, MD
Secretary Ian McLachlan, MD
Treasurer Sarita Satpathy, MD
Immediate Past President Dennis Song, MD, DDS
SFMMS STAFF
Executive Director
Conrad Amenta
Associate Executive Director, Public Health and Education
Steve Heilig, MPH
Director of Operations and Governance
Ian Knox
Director of Engagement
Molly Baldridge, MPH
Senior Director, Advocacy and Policy
Adam Francis, CAE
2024 SFMMS BOARD OF DIRECTORS
Edward Alfrey, MD
Melinda Aquino, MD
Julie Bokser, MD
Kristina Casadei, MD
Clifford Chew, MD
Esme Cullen, MD
Anthony DiGiorgio. MD
Manal Elkarra, MD
Mihal Emberton, MD
Cindy Greenberg, MD
Tracey Hessel, MD
Cynthia Lin, MD
Ian McLachlan, MD, Treasurer
Jason Nau, MD, President
David Pating, MD
Dawn Rosenberg, MD
Sarita Satpathy, MD, President-Elect
Michael Schrader, MD, Editor
Yalda Shahram, MD
Neeru Singh, MD
Dennis Song, MD, DDS, Immediate Past-President
Ranna Tabrizi, MD
Kenneth Tai, MD
Melanie Thompson, DO, Secretary
Christina Wang, MD
Kristin Wong, MD
Andrea Yeung, MD
Helen Yu, MD
For questions regarding journal, including possible submissions, contact Steve Heilig: Heilig@sfmms.org
PRESIDENT’S MESSAGE
Jason Nau, MD
Americans voted for change last November, and I knew this would not be an easy year as President of the Medical Society. Many, including myself, wondered what the impact on healthcare would be from the (real) agenda of the incoming elected President, Donald J. Trump.
The Future of Healthcare: Navigating Complexity and Uncertain Policy Changes
As healthcare professionals, we find ourselves at the intersection of policy shifts, economic pressures, and evolving care models. The US healthcare system has never been straightforward. Still, recent and impending federal policies demand our active engagement to safeguard access to care, optimize outcomes, ensure fair physician reimbursement, and stabilize the healthcare market.
The Healthcare Market: A Historical Anomaly
Unlike traditional markets, where consumers directly pay for goods and services, healthcare operates within a convoluted system shaped by historical policy decisions. Post-World War II wage controls led employers to offer health insurance as a competitive benefit, creating a landscape where third-party payers obscure the direct relationship between patient and provider. This system fosters inefficiencies, administrative bloat, and a preference for high-cost procedures and pharmaceuticals over preventive care.
While fee-for-service models have driven remarkable advancements in medical interventions, they have also contributed to soaring costs—particularly as chronic diseases linked to lifestyle and social determinants of health continue to rise. As a result, new models, including value-based care and public health-oriented policies, have gained traction. However, these approaches remain works in progress, requiring careful consideration and adaptation.
Policy Uncertainty and the Challenge of Reform
Recent policy shifts present challenges and opportunities, such as the Trump administration's push for price transparency, efforts to repeal the Affordable Care Act (ACA), and potential Medicaid cuts. The looming specter of Project 2025 adds another layer of uncertainty, forcing healthcare stakeholders to reassess what kind of system we genuinely want.
Applying the Stacey Matrix, we can categorize our current situation as complex—perhaps even chaotic—given the unpredictability of regulatory changes. Decisions seem influenced more by political expediency than long-term strategic planning, leaving physicians and healthcare administrators grappling with inconsistent directives. The volatility of tariffs and healthcare policy shifts further complicates strategic planning, making us need to develop flexible strategies.
The Reality of Price Transparency
The White House's recent push for healthcare price transparency aims to empower patients and drive competition. While this sounds promising in theory, its real-world efficacy is limited by the intricate ways healthcare costs are calculated and reimbursed. Unlike an auto repair bill, where pricing is straightforward, healthcare costs vary dramatically based on insurance contracts, network status, and negotiated rates. For most patients, the concern isn't the total cost of care but their out-of-pocket (OOP) expenses—a metric that transparency tools often fail to communicate effectively. Transparency is most useful for elective or "shoppable" services like imaging and outpatient procedures, but it falls short for urgent and emergent care. Moreover, in highly consolidated markets, price transparency can have unintended consequences. Instead of driving prices down, it can normalize higher rates as providers align their charges with the highest reimbursed amounts.
Despite these challenges, improvements can be made. Transparent pricing tools must provide accurate, user-friendly OOP estimates for deductibles, copays, and coinsurance. Moreover, price transparency should be paired with quality metrics to help patients assess value rather than cost alone, mitigating the misconception that higher prices equate to better care.
What Patients Want vs. What They Get
If we examine patient behavior, a model emerges that resembles what Medicaid (Medi-Cal in California) provides:
• No copays
• Seamless access to primary, specialty, and emergency care
• Advanced imaging and consultations without barriers
Kaiser Permanente historically exemplified many of these principles before the ACA required tiered, deductible-based plans. While there were past criticisms about quality, much stemmed from perception rather than reality. KP had (still has?) a branding problem that holds to the notion that a hospital's quality is inversely proportional to the grandeur of its lobby. Objective measurements regarding population care related to cancer screening, vaccination, and chronic disease management demonstrate high quality and value.
The Rise of Direct Primary Care (DPC) and Market Evolution
For families facing $10,000+ annual deductibles, the traditional insurance model often fails to deliver perceived value. This frustration has fueled the rise of Direct Primary Care (DPC)—a model that bypasses insurance in favor of subscription-based, direct-to-physician relationships.
DPC offers significant promise: higher pay for primary care physicians, improved continuity of care, and a financial
continued on page 24
EXECUTIVE MEMO
Conrad Amenta, SFMMS Executive Director
EMPHASIZING THE COMMUNITY-WIDE BENEFITS OF PROTECTING THE MOST VULNERABLE AS FEDERAL THREATS TO MEDI-CAL LOOM
As physicians in San Francisco and Marin counties, you are acutely aware of the diverse and often complex needs of your patients. Among these, the most vulnerable populations— such as the elderly, low-income individuals, those with chronic illnesses, and marginalized communities—require special attention and care.
We face an uncertain environment of federal policies that may have outsized effects on access to and quality of care for the most underrepresented and underserved populations in San Francisco and Marin. Republicans in Congress may choose to reduce or eliminate federal funding for the Medicaid program, such as that set out in the Affordable Care Act. At this time, it’s important that we continue to emphasize that protecting vulnerable groups of patients not only fulfills our ethical duty as healthcare providers but also yields significant downstream benefits for the entire community.
When we prioritize the health and well-being of the most vulnerable, we create a ripple effect that enhances the overall health of the community. Here’s how:
Reduced Healthcare Costs: Preventive care and early intervention for vulnerable populations can significantly reduce the need for expensive emergency care and hospitalizations. By managing chronic conditions and addressing health issues before they escalate, we can lower healthcare costs for everyone. This, in turn, can lead to more resources being available for other critical healthcare needs.
Improved Public Health: Vulnerable populations often face higher risks of infectious diseases due to factors like crowded living conditions and limited access to healthcare. By ensuring these groups receive adequate care, we can reduce the spread of infectious diseases, benefiting the entire community. Vaccination programs, regular health screenings, and access to primary care are essential components of this strategy.
Enhanced Social Stability: Health disparities often correlate with social and economic instability. By addressing the health needs of vulnerable populations, we contribute to greater social stability. Healthy individuals are more likely to be productive members of society, which can lead to reduced crime rates, improved educational outcomes, and stronger local economies.
Increased Health Equity: Health equity is achieved when everyone has the opportunity to attain their highest level of health. By focusing on the most vulnerable, we move closer to this goal. Health equity benefits everyone by creating a fairer, more just society where all individuals can thrive.
To realize these benefits, it is crucial to implement targeted strategies that address the unique needs of vulnerable populations. Here are some effective approaches:
Community Outreach and Education: Educating vulnerable populations about preventive care, healthy lifestyles, and available resources is vital. Community health workers, mobile clinics, and partnerships with local organizations can help bridge the gap between healthcare providers and underserved communities.
Integrated Care Models: Implementing integrated care models that combine physical, mental, and social health services can provide comprehensive support for vulnerable populations. This approach ensures that patients receive holistic care that addresses all aspects of their well-being.
Policy Advocacy: Advocating for policies that support vulnerable populations is essential. This includes pushing for expanded access to healthcare, affordable housing, and social services. Physicians can play a crucial role in shaping public policy by sharing their expertise and experiences with policymakers.
Telehealth Services: Telehealth has emerged as a valuable tool for reaching vulnerable populations, especially those in remote or underserved areas. By offering virtual consultations and remote monitoring, we can ensure that patients receive timely care without the barriers of transportation or geographic distance.
Professional associations, such as the San Francisco Marin Medical Society, play a pivotal role in supporting these efforts. By joining forces with your colleagues, you can amplify your impact and advocate for systemic changes that benefit vulnerable populations. Associations provide a platform for collective action, enabling you to share best practices, engage in advocacy, and access key resources in a timely way.
Protecting the most vulnerable populations is not only a moral imperative but also a strategic approach to improving the health and well-being of the entire community. By prioritizing the needs of these groups, we can reduce healthcare costs, improve public health, enhance social stability, and promote health equity. As physicians in San Francisco and Marin counties, your commitment to this cause can create a healthier, more resilient community for all. Through targeted strategies and active participation in professional associations, you can make a lasting impact that benefits everyone.
RESISTANCE IS OUR RX
Michael Schrader, MD, PhD
“The only way opinions and ideas can be renewed, hearts enlarged, and human minds developed, is through the reciprocal influence of men upon each other.”
The ongoing Trump administration “shock and awe” strategy to attack pillars of American democracy, science and medicine have been disquieting, disconcerting, and and dispiriting. I know I have wrestled with discouragement and the feeling of being overwhelmed at the onslaught of attacks on American science, medicine, and basic decency and fairness.
We are seeing attacks on public health, world health, vaccines, reproductive care, transgender care, the ACA, Medicare fee for service, Medicaid and Medi-Cal funding, insurance for pre-existing conditions, and generally comprehensive and affordable medical care everywhere. As physicians we know that what harms some of our population affects us all. The proposed changes will undermine our universities, our public health and ultimately our profession.
But Americans do not quit when they are faced with adversity. We did not quit when the Continental Army wintered at Valley Forge, when our country fought the Civil War to end slavery, when women and later African Americans fought for suffrage, and so many other times when the opposition looked insurmountable.
And your San Francisco Marin Medical Society does not back down. During the first Trump administration we stood up for funding for the NIH, the Affordable Care Act, Title X women’s healthcare, the humane treatment of detained migrant children, reasonable restrictions on firearms, and diversity and inclusion in our profession. We don’t stop there: A minor swing in the preference of the electorate driven by inflation and wealth disparity driven by Republican tax breaks does not change our vision and our charge. We stand for our profession, our community, and healthcare for our citizens.
Our SFMMS leaders and membership personify diversity, integrity, capability, and dedication. We are leaders in the community and the state and our influence extends to the national level. We will resist threats, amend cutbacks and then work to reconstruct science, medicine, and public health.
What can SFMMS do? Our delegation leaders have written a resolution to be submitted as an emergency resolution to the CMA Board of Trustees asking for more advocacy from the
AMA to fight the cuts to medicine and science. We also plan to submit a policy resolution to protect physicians from being forced to cooperate with ICE in healthcare facilities. We will propose a Major Issue to the CMA House of Delegates supporting continued current funding of Medicaid/Medi-Cal.
What can we as individuals do? Participate in politics: many of our local politicians support science and medicine. Discuss with other people: our patients need to know that cuts will affect their finances and health. March in the streets: the recent March in San Francisco and other cities to support science. We can collect stories of people who are injured by cutbacks.
What can we as consumers do? The power of the pocket book: Don’t buy Teslas, don’t shop at Target, don’t order from Amazon, don’t subscribe to the Washington Post. Shop at Costco because they support diversity, equity and inclusion. Follow the lead of Dr. Laura Esserman (in our previous issue) and eschew conferences in states where reproductive rights are denied.
Alexis de Tocqueville, who analyzed American democracy in the mid 1800s, saw collective action as an underpinning of American democracy: “The only way opinions and ideas can be renewed, hearts enlarged, and human minds developed, is through the “reciprocal influence of [people] upon each other.”
Chaos and confusion is their power but disorganization and lack of a coherent plan is their weakness. And real patriotism is our prescription.
Dr. Schrader, an internist at Dignity Health, is Chair of the SFMMS delegation to the CMA and a past-president of the SFMMS.
CMA’s 2025 President: SHANNON UDOVIC-CONSTANT, MD
The SFMMS is extremely pleased and proud to have our own Shannon Udovic-Constant, MD as this year’s President of the California Medical Association. A pediatrician trained at UCSF and working at Kaiser San Francisco, she has long been well-known and respected at the SFMMS due to her long path through our leadership roles, starting as a delegate to the CMA House of Delegates through serving as president, then chairing the CMA board of trustees and then being elected President. She takes that lofty leadership position in an especially critical time and we wanted to have a talk with her here.
– Michael Schrader, MD and Steve Heilig, MPH
You are the current President of the CMA. What got you involved with leadership in organized medicine?
Early in my pediatric practice I had 30% of my patients meeting the definition of childhood overweight and I was diagnosing Type 2 diabetes in adolescents. In talking with an elementary school patient about drinking water and not sugarsweetened beverages he said, “I can’t drink water”. It turned out his SF public school didn’t have potable drinking water. I knew how to address this with a single phone call to the AAP-CA executive director and legislation was passed requiring all California schools to have potable drinking water. Early on I saw the power of organized medicine to influence health policy and decision-makers to impact beyond my office walls the health of my patients and our community. Partnering with organized medicine thru the American Academy of Pediatrics, SFMMS and CMA would fast track the outcomes I was seeking. I pursued leadership because it allows you to create more impact.
SFMMSisoftenatraininggroundforleadershipattheCMA andinthecommunity.Whatdidyoulearnaboutleadership while being involved with SFMMS?
The importance of having processes in place and a culture that celebrates and welcomes diverse perspectives whether it be specialty, gender, age, ethnicity, type of practice. This leads to better decisions and alignment of the group that then allows focus on strategic priorities.
You are only the fifth woman to serve as CMA President. What special obstacles do women face in leadership in medicine?
There is a lot of programming that occurs early on in life about what a leader looks and acts like. When girls are young and they show leadership they are labeled as “bossy” which is not a compliment. Then, when a woman raises her hand or says she wants a leadership role it can be considered aggressive, when for a male leader it is seen as decisive. We know from science that the most effective leaders have traits that are considered traditionally masculine (assertive, decisive, etc) and feminine (collaborative, empathetic, etc). We all need to
learn ways to not have negative consequences when leadership traits are flexed that go against conditioned programming. This happens when you develop strong relationships with the people you are working with.
And to follow up: What can we do to address this problem?
We can all make our unconscious biases more visible. Ask someone he is talking over someone to wait until the person finishes talking. Call it out if someone takes credit for an idea that was someone else’s first. Create processes for all voices to be heard—specifically ask a member of your board who hasn’t spoken yet if they have something to contribute, go around the entire board and ask everyone to say 1-2 minute comment, invite women into your Board rooms and onto your Executive Committees. Then, we can create processes that make it easier for those underrepresented in leadership to indicate their interest—clear job-descriptions, clear systems for when and how those interested should indicate interest, clear processes for campaigning and running elections, and of course mentorship.
We are seeing a backlash against DEI or as CMA likes to call it: JEDI. How do we forward diversity when it has lost some popularity or momentum?
Physicians are scientists. We have data that shows that diversity leads to better health outcomes, improved health care quality, better decisions by Boards, and improved financial bottom lines for companies. So physicians should use the data to explain our “why” for continuing this important work.
We are in the midst of a doctor shortage with primary care being the most affected. As a practicing pediatrician, what do you see as possible solutions?
Physicians must be the leaders over the decisions that impact their patients. Physicians must engage in practice environments that allow them to get procedures/specialists/medications that they order for their patients, physicians must demand contracts to allow this, and we must get paid for the care that we provide that allow for financially sustainable practices. We must advocate for investment in GME and protect the funding that we
have. We also must show medical students the joys of practicing primary care so they want to come and join us! I am most proud of my positive evaluations from teaching UCSF medical students and showing them my love for taking care of wonderful pediatric and adolescent patients and the relationships and trust that are built in primary care. I have even started taking care of some of my former patient’s babies. So incredibly rewarding to know that you have that trust!
Whatarethebiggestchallengesyouseetomedicinetoday?
There is so much administrative red tape that pulls us away from direct patient care. This leads to burnout and also makes no financial sense as we look to improving affordability in healthcare. Physicians need to be working at the top of their license taking care of our patients and not fighting with bureaucrats for the care that our patients need.
Howcanorganizedmedicinestayrelevantasphysiciansare increasingly employees?
Associations such as SFMMS, CMA and specialty societies must facilitate all individual physicians having the leadership skills and opportunity to raise their individual leadership voices over the issues that matter for our profession and practices. Then, these associations need to have strategic focus to take collective action on those big issues directly impacting our physicians and profession. The hardest part for leaders and organizations is to have that laser focus so that limited resources of time and money can act on the issues that will have the greatest impact. Then, we need to communicate about the impact that was accomplished so members see the value of their membership!
As you know physicians and especially women physicians have a higher rate of problems such as depression and suicide. What can we do to address the problem of mental illness among physicians?
A physician’s work is hard—even the best of us will have difficult outcomes and encounters. We need to take care of ourselves and each other. If you are struggling please reach out for help. If you notice someone struggling please ask them how they are doing and let them know you care. Also we know that certain events can be especially hard such as a bad outcome, a mistake, being sued, and on the personal side—illness for self or a loved one or trouble with relationships. Talk to someone—a colleague, someone in Employee Assistance, a therapist. Please do not do it alone. CMA is making this easier as legislation passed to remove questions on the California medical license application/renewal to remove barriers to seek help for mental health/substance use and now Assembly Bill 408 (Berman) has been introduced to reinstate the Physician Health Program for physicians to seek help from a confidential program that meets National best practices.
TheSanFranciscoBayAreahasalwaysbeenathoughtleader forourcountryandSFMMShasbeenattheforefrontofsome of the national public health efforts. How can we forward public health initiatives about tobacco, sugary beverages, firearms, reproductive care, healthcare access, aid in dying and so on nationally?
SFMMS and other associations must continue to push forward our advocacy agenda. Please do not lose hope. Advocacy is a long game. It can take years to see something you have worked hard on to finally gain some traction. I recommend working with others so you can continue to get encouragement and also create small goals so that you celebrate along the way and not just wait for the big win to acknowledge your successes. Another strategy I have taken is to have a few advocacy goals that I am working on at the same time. This way if one is not moving, hopefully one of the others is.
YouwereraisedinafamilycoveredbyMedi-Cal.Thepassage of Proposition 35 was a big victory for California and the CMA. How might your personal history influence your commitment on this issue and the ongoing efforts to keep such programs strong and even expanding?
Access to healthcare is personal for me. As you indicate growing up my family had Medi-Cal insurance. We had to drive into another county to find a pediatrician to provide care for my family. Health insurance is only helpful if it leads to access to care.
The low reimbursement of Medi-Cal has been such a barrier to access. CMA heard from many physicians that they wanted to accept patients with Medi-Cal but they couldn’t make their practice budgets work due to the low reimbursement. Now with this momentous victory of passage of Prop 35 we can stabilize Medi-Cal reimbursement to allow more physicians to participate in the program which will lead to an increase in access. Now we must protect Medicaid funding at the National level as well. This is why we went into medicine - to provide the care for those who need us the most!
SFMMS CMA Delegation Report STANDING UP FOR HEALTH
The elected SFMMS delegation to the CMA House of Delegates represents our society and its members in a number of ways, including presenting resolutions to be discussed, debated, and considered for adoption as CMA policy. Through the decades, our delegation has had more such policies adopted by CMA and, for policies of national relevance, by the AMA, than any other.
The elected SFMMS delegation to the CMA House of Delegates represents our society and its members in a number of ways, including presenting resolutions to be discussed, debated, and considered for adoption as CMA policy. Through the decades, our delegation has had more such policies adopted by CMA and, for policies of national relevance, by the AMA, than any other.
Given the current national chaos regarding virtually all aspects of health care policy and delivery, we judged it worthwhile to issue statements supporting longstanding ethical values and
obligations in medicine and public health, and to submit these as resolutions to be considered for adoption as CMA policy.
One resolution restates the commitment of medical organizations to promote evidence-based medical practice and public health policy, to prohibit censorship of medical data and information; to maintain funding of medical care and research; and to ensure policy is crafted with the guidance and input of established, respected medical and public health leadership.
The second resolution supports the sanctity and confidentiality of the doctor-patient relationship and the protection of immigrants and other minoritized patients against immigration enforcement actions in health care facilities.
These two proposed resolutions are published here for member review. There is more work underway along these lines. If you have any feedback, please feel free to get in touch: heilig@ sfmms.org.
PROTECTING PHYSICIANS FROM COERCION BY IMMIGRATION AND CUSTOMS ENFORCEMENT
Michael Schrader, MD, PhD
Whereas, current federal policy is focusing on deporting seekers of legal asylum and other undocumented US residents; and Whereas, the fear of being reported to ICE prevents victims of sexual or physical assault from seeking care or from pressing charges against their attackers, and Whereas, forcing clinicians and medical facilities including hospitals and clinics to participate in immigration enforcement efforts will compromise patient access to medical care and will violate established medical ethics and the Hippocratic Oath to first do no harm, and, Whereas, forcing physicians to act against their conscience is a moral injury that harms the well being of our workforce, and Whereas, the relationship between physician and patient is protected under the law, now be it
RESOLVED, That CMA urges that all clinicians, hospitals and other health facilities avoid and minimize any actions that may compromise the provision of all indicated health services to minoritized or marginalized populations, including people who are or are assumed to be immigrants, ethnic minorities, and/or gender minorities, in line with recommendations of the California Attorney General and other relevant officials and organizations; and be it further
RESOLVED: the CMA reaffirms the sanctity and confidentiality of the physician-patient relationship, and proactively develop resources to assist physicians who may be asked or pressured to violate this relationship, and training of physicians and health care staff in ethical responsibilities.
RESOLVED: That this be referred to the AMA for national action.
San Francisco Marin District VIII Delegation
EMERGENCY CMA RESOLUTION: RESTORING SOUND MEDICAL, PUBLIC HEALTH, AND SCIENCE LEADERSHIP
Whereas, evidence-based medical, public health, and science policy leadership is foundational to global health security, disease prevention, and scientific progress; and
Whereas, coordinated public health efforts—spanning local, national, and international levels—have historically reduced disease burdens, mitigated health risks, and improved quality of life, driving both human and economic progress, while enhancing global resilience against emerging health threats and generally but consistently contributing much more economically than costs as a solid “return on investment”; and
Whereas, the threat of new and worsening pandemics, antibiotic resistance, environmental health factors such as climate change, and more are a threat to our national health and security and require an increased commitment to supporting public health efforts worldwide, as such threats respect no borders; and
Whereas, adequately supporting and funding university and other medical and public health research and training is an integral part of continually improving evidence-based medical and public health work, and requires including appropriate support for the institutions and infrastructure wherein such research and training are conducted and funded; and
Whereas, while continually evaluating and refining all public health programs and medical research efforts to be as costefficient as possible is a worthy and important goal that must be carefully approached and supported, rashly reducing or even eliminating public health programs, curtailing informational resources, and reducing national and international cooperation in advancing public health and medical research, education, and humanitarian health work is counterproductive, economically short-sided, and inhumane; Now be it:
RESOLVED: That CMA strongly supports evidence-based public health programs at all levels and urges that such programs be fully maintained and restored, including but not limited to the
United States re-joining the World Health Organization and International Climate Accord, restoring full funding and staffing at the Centers for Disease Control, National Institutes of Health, Food and Drug Administration, USAID, and other health agencies; and be it further
RESOLVED: That CMA reaffirms full support for approved vaccination protocols and efforts, restoring full availability and access of uncensored scientific/medical/ public health information via all public health agency websites and other resources; and be it further
RESOLVED: That CMA continues seeking to maximize any and all efforts aimed at preserving and expanding access to care wherever and however possible including preserving the ACA and, and reaffirming long-established funding formulas including reasonable administrative overhead levels for funded health research; and be it further
RESOLVED: That CMA urges that all important national decisions and policies regarding such resources and programs should be fully informed by and only carried out with the input and support of established and respected medical and public health leadership organizations and associations such as the American Public Health Association, American Medical Association, National Academy of Sciences, etc., and be in line with accepted medical and public health knowledge and opinion; and be it further
RESOLVED: That the CMA will urge the US Surgeon General and the Secretary of HHS to strongly oppose the recent and proposed cuts to public health funding, research, and health information dissemination of all data critical for research and improving health; and be it further
RESOLVED: That this be referred to the AMA for national action.
5. Eliminate Drug Ads on TV
We stopped broadcast advertising for cigarettes in 1971. Admittedly, the tobacco folks just advertised more in magazines, newspapers and billboards, but cigarette smoking has decreased by 73% among adults due to public awareness of the extreme dangers of smoking. The US and New Zeeland are the only two countries that allow pharmaceutical advertising directly to patients. $6.58 billion was spent annually on TV advertising in 2020. Notice that the ads are for expensive branded medications, which drives inappropriate drug prescribing. There is absolutely no reason for pharma to directly advertise expensive prescription drugs to patients, except to make big Pharma even more profitable. And to pay for expensive lobbyists to curry favor with politicians.
I could write much more but that's enough for one reading. Everyone agrees with eliminating fraud, waste and government inefficiencies. So far I haven’t seen any DOGE cuts that achieve that goal. If chaos, causing world disease and hunger, increasing unemployed ranks, eliminating consumer protections, making America sicker and more anxious is the goal...it is being achieved. Stay tuned.
Toni Brayer, MD is an internist and former president of the SFMMS, chief of the medical staff of CPMC, CEO of the Sutter Pacific Medical Foundation, and much more. She writes at www.EverythingHealth.net
LASTING IMPACT: PATIENT STORIES
We’ve had an intermittent series wherein respondents provide short answers to the question “What patient has had the biggest impact on you thus far?” if you are interested in contributing, send your story to Heilig@sfmms.org.
VICTIMS OF INJUSTICE
David E. Smith, MD
In June 1964, right after I graduated from UCSF, I was on duty as an intern in the SFGH emergency department on the final night of the Republican convention here. I was watching an attending physician stitch cuts on the face of a drunk Rockefeller delegate who’d been hit by a drunk Goldwater supporter at the Republican convention. A call came rang through the hall for all surgeons: There was an incoming car accident victim with legs amputated to mid-thigh.
“Finish up,” my supervisor told me, as he sped out of the room. The last stitching I’d done was to place electrodes in the back of a hibernating hamster, but there was no time for my insecurities. I got to work on my patient. Just like my hamsters the patient did well; it was a great lesson in county hospital emergency medicine. But simple cases like those would never truly prepare me for the heartbreaking losses – especially those cases that piqued my awareness of social injustice. So, another time, a woman came in feeling “very sick.” She spoke Spanish, and the teenage daughter who accompanied her translated for me as I did the intake, took her vitals, and inserted an IV for fluids. She had shaking chills but no fever, which suggested she was in septic shock. I asked the daughter what had happened. Suspecting that I was seeing the aftermath of a botched abortion, I explained that this could kill her mother. The daughter her alcoholic father had left the mother
raising three children alone. The mother became pregnant and, despite being a devout Catholic, had gone for an illegal abortion.
With that information, we rushed her to the operating room for an emergency hysterectomy. It was too late. She died on the table. She lost her life because the law forbade the prompt medical care she needed, and because her family felt they had to delay treatment as her condition worsened. I have been pro-choice ever since. And now a teenage girl would be responsible to raise two children without a mother or a father. I can’t fathom how anyone who has had to care for a woman brutalized in this way could ever be against the right to choose. In my childhood, I witnessed my mother giving dedicated nursing care when she herself was suffering. I saw my father get the care he needed, even though it did not save his life. I wasn’t prepared for this: I watched a woman die because judgmental others stood between her and medicine’s ability to save her life.
David E. Smith founded the Haight-Ashbury Free Clinics in 1967, was a co-founder of the specialty of Addiction Medicine and a President of the American Society of Addiction Medicine, has received UCSF’s highest awards for service to medicine and public health, and is a 53-year member of the SFMMS.
Section: Standing up for health
‘I’M AFRAID FOR MY PATIENTS’: HOW TRUMP’S DEPORTATION PLANS ARE HITTING CALIFORNIA HOSPITALS
Theresa Cheng, MD, JD
It was 2018 when I received the ambulance radio call that haunts me to this day.
I had just started my career as an emergency doctor in Los Angeles. A 21-year-old man had been pinned between a cement truck and a concrete wall. When he tried to walk, all he felt was immense pain. An ambulance was called, but he refused to go to an emergency department.
It was part of my job to advise the paramedics by his side what to do. I feared that he might have broken his hip or leg or had internal bleeding. He could have died. But despite my pleading with him on the radio, he refused all help. When I asked him why, he told me he was afraid that he would be deported. I could not convince him otherwise. Paramedics were forced to watch as his family carried him away to a destination unknown.
Trust is the cornerstone of patient care. Hospitals are meant to be places of refuge and healing. Under the federal Emergency Medical Treatment and Labor Act, emergency departments are required to provide care to all comers, regardless of citizenship status. There, we often see and take care of patients on their worst days. We ask them and their loved ones deeply personal questions and perform invasive procedures with assurances of our medical integrity. But now, with the Trump administration’s decision to allow ICE into sensitive location like medical facilities and schools, hospitals have been weaponized as potential locations of surveillance and arrest.
I wanted to see this man get the care I thought he needed. But his fear of being detained at the hospital was warranted. And for people in similar positions, it is once more under President Donald Trump’s new administration.
While hospitals were once considered sensitive locations to Immigration and Customs Enforcement officials — where they are not allowed to conduct their business, including arrests — the Trump administration has already done away with this federal policy.
An immigration crackdown is unfolding across the country. Thousands of military troops have been sent to our southern border. Raids on farm workers in the Central Valley have been executed. A Los Angeles father was detained in front of his son going to school. Military and commercial planes have begun deporting people to Guatemala and Mexico. The fear among migrants and their families is pervasive and at an all-time high. As an emergency medicine doctor working in a public, safety-net hospital in San Francisco, I am also afraid. I am afraid for my patients. I know how widespread fear of immigration enforcement leads to a chilling effect where patients are too afraid to seek medical care. I have personally seen how deadly the fear that surrounds these crackdowns can be.
It is well-documented that when patients don’t feel safe, they won’t access health care, which can lead to poor health outcomes. Over half of undocumented Latino migrants interviewed in a study during the last Trump administration reported that their fears caused them to delay coming to the emergency department by several days. This chilling effect also leads to increased fear of reporting violent crimes to law enforcement, seeking help for intimate partner violence and going to school.
Patients who are too afraid to seek medical care risk allowing their acute or chronic diseases to worsen with potentially catastrophic consequences. High blood pressure can lead to a stroke. A wound can become sepsis. Fear and the subsequent chilling effect will lead to the spread of infectious diseases and deaths in our communities that otherwise would have been preventable.
The emergency department becomes a place of last resort that may be too late for some. Already my colleagues in the Central Valley are reporting an uptick of pregnant migrant women missing critical appointments. Some pediatric clinics in San Francisco are now described as “ghost towns.” Just a month ago, I performed CPR on a young woman and had to pronounce her dead from untreated diabetes. It’s a condition that no one should die from in America. She had not sought health care for months because of her undocumented status.
Politics has no place in hospitals and emergency
departments. Patients shouldn’t have to choose between health and arrest. Doctors shouldn’t have to feel the moral injury of choosing between care and compliance.
I still wonder about that young man in Los Angeles. Is he permanently disabled from a leg injury? Was he brought home to bleed to death? Was there more I could have done to convince him to come in? How can I persuade patients to seek care at the risk of detainment and deportation? They are at risk either way of losing the lives they know.
We cannot let fear compromise our commitment to caring for and earning the trust of our patients. Despite California declaring itself a sanctuary state in 2017, it can — and must — do more to strengthen its laws surrounding the protection of its immigrant communities. California could strengthen its position as a sanctuary state by enacting more stringent policies around data sharing between state and federal law enforcement.
Meanwhile, hospitals and emergency departments must proactively develop clear internal policies and staff education around interactions with law enforcement, constitutional Fourth Amendment rights and federal privacy acts. We need stronger and more transparent protections and protocols for our migrant patients. We must be able to reassure them that they do not need to be afraid for their lives when seeking help at spaces of healing.
Theresa Cheng is an assistant clinical professor at UCSF, an emergency medicine doctor at Zuckerberg San Francisco General Hospital and a civil rights lawyer. This op-Ed first appeared in the San Francisco Chronicle in February.
RENEW: LOOKING BACK AND MOVING AHEAD
Linda Hawes Clever, MD, MACP
In the 1990’s, the advent of “managed care” upset Medicine’s apple cart. Suits (referring to clothes, not litigation) started to impact medical decisions. Worse, clinicians—physicians, nurses, and more were reduced to being called “providers”. In fact, you had to be designated a “provider” in order to get paid! No longer were we “professional.” “Professional” stems from the Latin “profess”—“to take a vow.” We do that. We pledge our purpose to uphold a variety of ethical standards, to keep on learning, and to do no harm. That dedication is quite different from being a “provider”, who simply supplies an item, like shoes or a used car, or performs a service such as painting your house.
and other clinicians, usually in groups by profession. Capitalizing on the benefits of conversations, we developed a “Conversation Group” format so people could connect with each other. To enter a conversation means that a person is willing to listen and consider change, not rant, rave or debate. In Latin, con = with; versus = turn. Thus, you are willing to “turn with” another person. Conversations don’t just shuffle the deck. They add new cards.
In 1998, in response to these changes and prompted by my own set of personal tragedies of deaths, disappointments and disruptions, colleagues and I, with the support of now-California Pacific Medical Center, including its Institute for Health and Healing, founded the not-for-profit, RENEW. Our purpose was and is to assure vigor, optimism and enthusiasm in the health professions and their practitioners in order to achieve better health for our patients and ourselves.
RENEW works in small and large groups over short or long periods. Physicians revisit values, redefine goals, rebuild hope and regain effectiveness, so that they and their patients cross the finish line together, enjoying whole, healthy lives. This is no easy task.
RENEW started by listening. The messages we heard then and now include:
• Physicians can get exhausted, doing good.
• Physicians want to be better than busy.
• When physicians suffer, their families, friends, communities and patients all suffer.
• Nurses and other clinicians are hurting. They, too, want to practice the professions they love and yet have full, flourishing personal lives.
The clear question: how best to spend time wisely, since all we have is time, and time is love.
Over time, RENEW transformed our listenings to presentations, often at grand rounds. These presentations outlined basic questions and how to address them. One early title was, “Putting the Joy Back in Medicine—and Life.” We soon offered conferences, seminars (now webinars), and retreats (I think of them as “advances”). We extended our work to include nurses
I wrote a book, The Fatigue Prescription: Four Steps to Renewing Your Energy, Health, and Life. Topics covered a span of RENEWing topics such as values and purpose; dealing with change; boosters to renewing; self-esteem and courage; why and how to say “yes” or “no” at the right time; and five features of people who consider themselves to be in good shape, or FIT.
As it happened, over RENEW’s next years, the world continued to change. Knowledge, new treatments and cures increased as did new pressures and restrictions. COVID stormed in. One session of a RENEW COVID series was entitled, “When You’re Going Through Hell, Keep on Going.”
Now, as society marinates and boils in worldwide unrest and wars, and divisiveness explodes, relationships often fray. So, in addition to RENEW’s time tested, successful content, we are adding new dimensions to our offerings.
Specifically, RENEW is helping groups of physicians, nurses, other clinicians, and leaders in the not-for-profit sector communicate constructively as we repair, refresh, replenish, and restore ourselves and our communities, even our country. The goal is to learn how to engage in civil discourse. Like personal renewing, building bridges takes work, yet is worth every moment.
It is clear that solving our own problems and those in medicine, society, family, and neighborhoods, is enhanced by engaging in conversations, as RENEW has always done. We offer some basics to start.
Jonathan Levin, the new president of Stanford University, said at his inauguration, “Be open: Open to yourself; open to each other; open to the world.” Being open requires some humility, having a hunch that you may not know everything. Of course, being open may lead to learning, which might lead to change. Change can be hard, yet lifelong learning is part of our vow, our profession, and we do it on a daily basis.
WHY TRADITIONAL PHYSICIAN WELLNESS DOESN’T WORK—AND WHAT DOES
True wellness does not happen in conference rooms or even on a yoga mat. It does not come from resort buffets with chafing dishes. It does not come from sitting at long tables with stiff white tablecloths, taking notes with hotelbranded pens, watching PowerPoint slides on burnout.Even when held in the snow or on a tropical island, the old model of physician wellness is just that—old. Wellness that truly transforms medicine happens at a cellular level. It happens when we pause long enough to reconnect with ourselves and each other.
It happens in quiet spaces and shared laughter, in deep breaths and stillness, in real conversations, and realigning with what matters most. It can happen from home on Zoom, at a retreat, in person, in a small group, or one-on-one. It does not have to include CME. It does not have to be reimbursed. I paid out of pocket for my own professional development coaching (and subsequently coach training)—an investment greater than medical school. I was not reimbursed and I did not earn a degree or CME credits for it.
I would do it all again in a heartbeat. Why? Because, by investing time, money, and energy, in my own personal and professional development, I am a healthier, happier human. My relationships are stronger and deeper. And I have grown in ways that are aligned and deeply authentic. I have walked alongside hundreds of physicians who have experienced the same.
If you feel the pull to step into something different, consider gifting yourself change at a cellular level. Gift yourself time, space, and deep connection. Gift yourself a fresh perspective and a strategic mindset. If you feel like you “can’t,” don’t have time, energy or resources, recognize that the pain of staying where you are is greater than pain of changing things. Be courageous and let go of the old version of you, stop regurgitating the past, and see what real wellness feels like.
Jessie Mahoney is a pediatrician, a certified life coach for physicians, and a yoga instructor. She is the Chair of the SFMMS Physician Wellness Task Force. She practiced pediatrics and was a Physician Wellness leader at Kaiser Permanente for 17 years. She is the founder of Pause and Presence Coaching where she supports and empowers her physician colleagues using mindfulness tools and mindset coaching.
Recommended Listening: The Mindful Healers Podcast with Dr. Jessie Mahoney and Dr. Ni-Cheng Liang
Navigating Healthcare Drama: Setting Boundaries and Responding with Intention
From the frustrations of systemic inefficiencies to personal boundaries, this episode will help you reflect on how you respond to healthcare-related stress—and how to make intentional choices that protect your well-being while still contributing to change. Healthcare is an incredibly human profession, full of complexity and challenge.
Breaking the Over Helping Habit: Valuing Your Expertise as a Woman Physician
Women physicians face pressure to give away their expertise for free, and feel intense guilt and discomfort when we say "no." This episode encourages all women physicians to reflect on how they give and receive help.
Learning to Hold Space and Compassion for Yourself with Dr. Yvonne Juarez
In this episode, Dr. Yvonne Juarez, a pediatrician and physician leader at TPMG, shares her transformative journey of selfcompassion, personal growth, and professional renewal.
Jessie Mahoney, MD
Gathering Our SFMMS Members in 2025
SFMMS has been busy this winter! Not only did we host our Annual Gala at Cavallo Point on February 8th, which you can find a summary of in this issue, SFMMS has held smaller, more intimate gatherings for our physician members to connect with one another. To learn more about our upcoming events and offerings, visit our SFMMS events page at https://www.sfmms.org/ news-events/events.
SFMMS Celebrates National Women Physicians Day at the Annual SFMMS Women in Medicine Mixer
Each year, we gather a group of our physician members who identify as women, for a meal, connection, and community building. This year, we celebrated National Women Physicians Day at SIP Tea Room in San Francisco.
“[The Women in Medicine Mixer] was another incredible event. It was the perfect opportunity to connect with my fellow female colleagues, especially during this trying and overwhelming time!” – SFMMS Member
“Wow, I didn’t know how much I needed that! It was lovely to hear from physicians who have had the same experiences as me in medicine.” – SFMMS Member
SFMMS gathered a group of 15 physicians, virtually, in January for our physician members to discuss “Legacy: A Black Physician Reckons with Racism in Medicine” by Uché Blackstock MD.
The definition of legacy, “something transmitted by or received from an ancestor or predecessor or from the past.” acts as a framework throughout the book to discuss the influence legacy can have in choosing to go into medicine, as in the case of the author and sister, who’s mother was a physician. As well as how the legacy of systematic racism in medicine, training, career trajectory, and the diagnosis and treatment of patients affects physicians’ ability to practice medicine. Our 90 minute SFMMS book club discussion of Dr. Blackstock’s book focused on our members’ own experiences with legacy in choosing to go into medicine, the social determinants of health, and how to prevent burnout in a large healthcare setting.
Stay tuned for information about our SFMMS next book club. If you have book suggestions for future book clubs, please email Molly Baldridge at mbaldridge@sfmms.org.
California Doctors in Retirement (CADRE) Gathers Monthly in Greenbrae
"The monthly CADRE meeting is always fun. This gathering is for special people, who have had unique lives. As retired SF and Marin physicians, we can be best understood by each other. "
Join your fellow retired physician colleagues for CADRE (CAlifornia Doctors in REtirement) for casual conversation, connection, & free coffee, monthly (3rd Thursday of the month) at Peet's Coffee in Greenbrae. For more information, please contact Molly Baldridge at mbaldridge@sfmms.org. Special thanks to Dr. Joan Saxton for her coordination and leadership of the CADRE group!
SFMMS Financial Planning Roundtable & Mixer
In March, SFMMS will gather a small group of our members for our first financial planning mixer. The goal of this first gathering is to help inform the financial planning needs of our physician members and future guests speakers for similar events. If you would like more information, please visit the SFMMS events page.
UPCOMING EVENTS
Join Your Colleagues at an Upcoming LOCAL Physician Wellness Retreat! May 10th, 2025 Honoring Diastole at Pie Ranch in Pescadero, CA is the ONLY Open Retreat in 2025!
“Amazing & transformational! I’ve been to many retreats and this is one of the best!” – SFMMS Member
Mindful Coaching, Yoga and Culinary Medicine. CME available. Find out more about both individual retreats here: https://www.jessiemahoneymd.com/retreats.
Are you looking for Additional Resources? The SFMMS Wellness page, curated by your SFMMS colleagues, includes upcoming and past wellness events, resources and more. Learn more by visiting the SFMMS Wellness page at www.sfmms.org/get-help/ physician-wellness or by scanning the QR code with your smartphone.
Would you like to Practice Mindful Yoga for Healers With Jessie anytime? Join Dr. Mahoney on Zoom most Saturdays at 9 am or anytime on YouTube. For more information visit: https://mindfulyoga.jessiemahoneymd.com or https://youtube. com/c/JessieMahoney.
IN THE NEWEST SALVO IN THE SODA TAX WARS, DAVID BEATS GOLIATH IN SANTA CRUZ
John Maa, MD
In November of 2024, David slayed Goliath in Santa Cruz, California in the latest chapter of the Soda Wars. A “small group of thoughtful, committed citizens” defeated the soda industry in the Measure Z campaign 52 to 48, despite being outspent 34 to 1 ($2.8 million to $70,000). The 2 penny per ounce tax on distributors that gross over $500,000 annually (raising the price of a 12 oz can of soda by nearly a quarter) will generate $1.3 million in annual revenue for community health investments .
Over my career as a general surgeon, I have witnessed the epidemic of obesity (especially in kids), diabetes and tooth decay sweeping across America. In the early 2000’s, the American Heart Association (AHA) recognized the rising rates of obesity in America and the potential impact on heart disease and strokes rates, and has been a champion in the effort to curb the hazards of sugar sweetened beverages, which represent the largest source of added sugar in the American diet. Sugary beverages are marketed relentlessly and often cheaper than a bottle of water, making the healthy choice not an easy one. The average American consumes 40 gallons of soda over a year—enough to fill a bathtub. But what drinkers of an average 12 oz soda don’t realize are the ten packs of sugar dissolved within. In 2024, sugar sweetened beverages placed a $173 billion strain on our healthcare system, and cost employers $400 billion including absenteeism and lost days. If we taxed all of the soda consumed in America at 2 cents per ounce, it would generate $34 billion of revenue annually.
The Bay Area soda tax movement began almost twenty years ago, when Steve Heilig attended a presentation by cardiologist Dr. Jeffrey Ritterman summarizing the evidence of sugar sweetened beverages on multiple serious and increasing health conditions. The idea was presented of using taxation to both disincentivize consumption and fund treatment and prevention efforts - as with tobacco. In 2009, Heilig drafted a CMA resolution with Dr. Shannon Udovic-Constant in support of a soda tax, and CMA delegate Dr. Lawrence Cheung and others advocated for the policy to be adopted first by SFMMS and then the CMA in October 2009. In 2012, the AMA joined with Policy H-150.933 “Taxes on Beverages with Added Sweeteners” introduced by the Council on Science and Public Health, that was reaffirmed in 2017.
As a Richmond City Council member, Dr. Ritterman championed the first Bay Area soda tax in 2012, but it was defeated by voters. In 2014 then-SFMS President Cheung and others campaigned unsuccessfully to have a tax passed in San Francisco. That same year, Berkeley passed the nation’s first soda tax with Michael Bloomberg’s support. In 2016 twin soda tax ballot measures in SF and Oakland became a Goliath vs Goliath battle between Michael Bloomberg and the American Beverage Association who together spent $47 million, shattering all spending records. Soda taxes spread in Philadelphia, Boulder Colorado, Seattle, and Chicago, all supported by Michael Bloomberg. What was witnessed in Berkeley was first a reduction in sugary drink consumption by 52% with an increase in water consumption by 29% consumption, followed by a decrease in average childhood body mass index (BMI).
Over 22 nations followed the Bay Area in 2016 to tax sugary drinks, including the United Kingdom. South Africa, Portugal, France, India, Malaysia, Philippines, Spain, Thailand and the UAE, bringing the total to over 50 nations. This provided strong population health data to guide further policy actions.
It was for this reason that the soda industry took drastic action to stop the movement. In 2018 beverage industry lobbyists gathered signatures for a California ballot initiative to prevent future local taxes to fund essential services like firefighting, schools and libraries. They forced California lawmakers and Governor Brown to ban new local soda taxes until 2031 in exchange for dropping their ballot measure. A 2018 Santa Cruz soda tax had been moving to the ballot, before the ban brought everything to a halt. In 2020, Santa Cruz Town Council Member Martine Watkins and ChangeLab Solutions challenged the ban in court. In 2023, a California appeals court struck down the ban’s penalty provision as unconstitutional, ruling that charter cities (like Santa Cruz and 108 of California’s 478 cities) have the constitutional right to govern their own affairs by enacting soda taxes.
So the Santa Cruz soda tax returned in 2024 under Martine and colleague Councilmember Shebreh Kalantari-Johnson. Keys to victory include the fact that 75% of Americans are obese or overweight, and the new environmental data that Coca-Cola
holds a top position in plastic pollution for 6 consecutive years. The soda industry deployed their old playbook—flooding the airwaves with television commercials and mailers in mailboxes. But their reliance on out-of-town communication firms, consultants and campaign staff created the negative perception that outsiders were trying to influence Santa Cruz elections. In contrast, the Yes on Z campaign knocked on nearly every door in Santa Cruz to educate voters, and utilized a local grassroots campaign to effectively educate voters.
In 2024, Berkeley also renewed their 2014 soda tax by passing Prop Z by an 80 to 20 margin, where Big Soda did not open an office or file an opposition ballot statement. Berkeley voters saw the benefit of soda taxes, which transformed grocery and convenience stores shelves with options to purchase water and low calorie and zero calorie drinks.
What was remarkable in the Santa Cruz victory is that it demonstrated a local soda tax can win with local grassroots support alone in the face of industry’s vast financial resources. In 2014, the SF soda tax Prop E garnered a majority of the votes at 55%) despite being massively outspent (though it did not become law as it was a special tax requiring a 2/3rd’s majority). The 2024 successes in Berkeley and Santa Cruz have illuminated the path forward and reignited sugary drink taxation across California and the nation. Several US cities are considering soda taxes in 2025, and the Legislatures in Maryland and Connecticut have recently introduced statewide soda tax bills.
In 2018, the California Medical Association proposed a statewide soda tax ballot measure, but did not enter the signature gathering phase after the soda tax ban was signed. That unfulfilled effort could serve as the foundation to try again with a California statewide soda tax in 2026, along with legislation to create a soda warning label, encourage healthy beverage options in restaurants, and overturn preemption. As of 2025, 119 nations now tax soda, and the WHO has endorsed the soda taxes. Perhaps someday soon, the United States can become the 120th nation in the world to tax soda.
John Maa, MD, an SFMMS past-President, serves on the board of directors of the American Heart Association Western States Affiliate. He was appointed by Governor Gavin Newsom to the California Tobacco Education and Research Oversight Committee and serves ex-officio on the University of California Office of the President Tobacco Related Disease Research Program.
SFMMS/CMA POLICY: SUGAR SWEETENED BEVERAGE EDUCATION AND TAXATION
Date Adopted: 10/19/2009
Resolved #1: That physicians should educate their patients about the health risks associated with the consumption of food and beverages containing high amounts of processed simple sugars or refined sugars such as high fructose corn syrup; and be it further
Resolved #2: That CMA support increased taxes on sodas and other relevant sugar sweetened beverages, with the revenues to be utilized for public health education efforts such as those conducted by the CMA Foundation and for other health purposes; and be it further
Resolved #3: That CMA encourage public health education campaigns on obesity prevention and treatment.
Resolution: 721a-09
PRESIDENT’S MESSAGE
continued from page 5
model incentivizing prevention over intervention. If scaled appropriately, DPC could help realign incentives across the system, potentially reducing the burden on emergency departments and specialist-driven care.
Balancing Cost, Access, and Value
The challenge ahead is striking a balance between accessibility and responsible resource utilization. While free healthcare may seem ideal, human psychology suggests that services perceived as free are often undervalued, misused, or taken for granted. A system that fosters appropriate patient investment— whether through structured copays, value-based incentives, or DPC models—may yield better outcomes.
What are my predictions for the near future? Some things that might happen include Medicare Advantage as the default payment model for Medicare, caps on drug prices introduced in the Inflation Reduction Act may be removed, and Medicaid may transition to block grants with lifetime limits and work requirements. Head Start programs are at risk. The ACA may be repealed, eliminating protection for preexisting conditions by removing essential health benefits for insurance. New "junk" insurance plans may be allowed to compete in the insurance marketplace. Reproductive health is at risk, as are Public Health mandates for vaccines (the consequences we already see). We have seen reduced investment in federal funding for research over the next year as institutions have already put on hold some research.
What are the consequences of this, and what can we do as physicians? Healthcare costs will likely increase with uncer-
tainty – insurance companies do not like uncertainty and will price accordingly. Patients will pay more out-of-pocket expenses. Costs will increase as the labor force shrinks due to the lack of Graduate Medical Education (GME) funding for physician training and the general loss of luster of the medical profession. Quality may decline, and doctor wait times may rise. I think you can guess how the general health of US citizens will go. Now is the time to tell your story. Narratives and stories are how societies change.
Physicians and patients alike need high-EQ providers equipped with a solid grasp of science, policy, and rhetoric. These providers must be capable of navigating the complexities of modern medicine without mistaking rhetoric for reality. Our role in shaping the future of healthcare has never been more crucial. I ask you, dear reader, to bring us your stories so we can amplify your message.
Jason Nau, MD, is an emergency physician at Kaiser Permanente in San Rafael, CA, where he’s been caring for his community for 26 years. A self-proclaimed serial hobbyist and amateur philosopher, he’s driven by curiosity, always eager to explore new ideas, and unafraid to have his beliefs challenged—and occasionally overturned.
Dr. Nau’s views here are his own and do not represent Kaiser Permanente.
