enormous success in san francisco and we believe that san francisco will be the model for the rest of the country on how to maximize its success of the aca because of the health care security ordinance. there's a last point that i want to highlight here before asking the department of public health to come and present, in 2015, the aca will include a requirement that employers provide insurance or pay a penalty if they do not provide health insurance to employees that work over 30 hours a week. what's going to happen as a result of this unfortunately, in many parts of the country to the extend that the threshold is at 30 hours a week, there's an anticipation that many employers will be lowering the number of numbers that employees work to 29 or under and because of the health care security ordinance, we know here in san francisco, an ordinance that goes beyond the coverage that the current law

provides, we believe that, that trend will not happen in san francisco because the health care security ordinance ensures that employees that work more than 8 hours are covered. this is yet another example of how the health care security ordinance and especially the employer spending requirement aspect of the ordinance can work very well with the aca to provide meaningful access to health care to all san franciscans, so with that, i want to thank all of the members of the public, members of the community, the business community, labor who are here, and so it is now my pleasure to call on our fabulous deputy director of public health, colleen chala who is going to make a brief presentation. is that okay? >> good afternoon, supervisors, i'm glad to be here on behalf of the health department.

i am as you side colleen, deputy director of health at the health department, i'm here on behalf of director garcia, she regrets she's unable to participate in the hearing today, but she is as we speak engaged in negotiations related directly to dpl's delivery system for the affordable care act. i also was hoping for the overhead too. san francisco has a long history of supporting health and health care in san francisco long before there was health reform, san francisco recognized the importance of health insurance and health care access and adopted cutting edge policies x programs that extended health insurance to more san franciscans, these included the healthy kids program which provides health insurance to low-income children, the health care accountability ordinance which requires contractors and less sees of city property to

provide health insurance to their employees and the health care accountability ordinance which you will hear about more today and healthy san francisco, our flagship program as supervisor campos mentioned. as employee of the public health system, i'm pleased to work in a place that puts high priority on health and access to health care and it's because of the citywide commitment that all san franciscans have a good health care home, we are doing this by connecting people to the insurance they're eligible for and to those that have no other options. we cannot afford to keep individuals on locally funded programs that are subsidized by the state or federal government. it will not be simple, it will require coordination and education and support and individual responsibility, but it is possible. what i'll talk about today will hopefully provide the foundation for today's discussion. today i will provide a general overview of health reform, kind

of a health reform 101, talk a little bit about the impact of health reform on the uninsured in san francisco, also about the aca implementation activity that dph and noel simmons will talk about the aca implementation verses at the human services agency. so, as supervisor campos said, it was assigned into law by president obama to expand health care coverage, it is the biggest initiative since the creation of medicaid and medicare, as a result of health reform , the rate of uninsurance will be reduced by half, and 92% of all u.s.

residents will have health insurance. locally, approximately 56 thousand san franciscans who are uninsured today will have access to health insurance. how does health reform propose to expand access too insurance? it requires that people have insurance and it gives them more options to obtain it. the requirement for people to have insurance is called the individual mandate as the supervisor mentioned previously. most but not all u.s. residents will be subject to the mandate which becomes effective on january 1. those that are not subject to the mandate include undocumented individuals, that will be the largest proportion of individuals not subject to the mandate. those experiencing hardships such as homelessness, people with incomes below the threshold for filing federal tax returns which is about 9750 dollars per year, the incarcerated, those are the religious exemptions.

>> my apologies, do you have copies of the slides for the committee. >> i'm sorry, i do not, i apologize. >> continue, please. >> anyone who is subject to the individual mandate and fails to show klein which will be done through their tax return, financial penalties will apply, the penalty in the first year is $95 which is low in acknowledgment of this new requirement but it creases to 695 dollars in 2016, it expands public insurance for low-income citizens through the medicate program, it creates the amazon.com of health insurance, it incentive employers to offer coverage, it makes health insurance more accessible and for all of these, i'll review the expanded options in brief.

for the lowest income individuals, health reform expanded medicate which is called medi cal in california, prior to health reform, only certain low-income individuals were eligible for medical, primarily, children, seniors, and families with disabilities, they compromise a significant portion of the insured, health reform changes this beginning january 1, adults ages 18 to 64 with incomes between 0 and 138% of the federal po*rt level which is about 15 thousand 800 dollars for a single person will be eligible for medi cal, the current medi cal program that serves these people will be unchanged. those newly eligible will enroll into managed medi cal, it's important to note that eligibility does not equal enrollment, enrollment is not automatic, even today, about

1.3 million californians are already eligible for medi cal but have not enrolled, individuals will have to apply for medi cal which they can do at any time during the year. our exchange is called cover california, cover california is an online marketplace where individuals can purchase health insurance. individuals who have incomes that are above the medi cal threshold and californians can buy health insurance on this stage. there are four standard tiers that will be offered, they're called bronze, silver, gold and platinum, the difference is their percentage of annual cost that is the health plan covers, bronze covers 60% of cost, silver, 70, gold, 80 and platinum, 90, there's a catastrophic plan that also

will be available. there are sliding scale subsidies available to low-income individuals on covered california up to 400 % of poverty which is about 46 thousand dollars a year for a single adult. half of the individuals expected to get health insurance through covered california [inaudible] currently five health plans are approved for offering in san francisco under undercover california, they are anthem blue cross, blue shield, the chinese community health plan, health net and kaiser. technically, there is no mandate on employers to provide health insurance under the affordable care act, instead there are incentives and penalties for employers to offer coverage. they can offer for affordable coverage on the exchange, and

for more full time employers, there is a financial penalty structure if employers offer no coverage or unaffordable coverage, no coverage is defineesed as an employer who offers coverage for fewer than 95% of its fte's and the employer is imposed if one employee receives a low-income subsidy on covered california, [inaudible] health insurance that covers less than 60% of health care expenses or costs an employee more than 9.5% more of their income, a penalty is imposed if one employee receives one subsidy. [inaudible] at a cost to an employee of no more than 9.5% of their family income would avoid any penalty.

these provisions were scheduled to become effective in 2014 but the obama administration delayed their implementation until 2015. and finally the final category under health reform that is making insurance more accessible is through the marketplace reforms, these set more standards for health surfers, subchaser guaranteed issued and renewal which refuses to [inaudible] that individual or group used in the prior year x the inability to deny individuals due to preexisting condition, creating a minimum essential benefit package, extending dependent coverage up to age 26 and eliminating cost sharing for prevention services. so, now i'll talk a little bit about the ill pact of health reform on san francisco's uninsured. the 2011 american community

survey which is part of the u.s. census estimates the rates of insurance and uninsurance, these data show that approximately 84 thousand san franciscans are uninsured, 60 thousand aof these are enrolled specifically designed to protect the unschroeder, healthy san francisco was created in 2007 to coordinate care for san franciscan's uninsured, this is by the department of public health as well as clinic, hospitals and physicians across the city, more than 50 thousand participants have access to more than 37 health care homes and they are provided with specialty services, pharmacy services, primary care services and more. sf task is a program that began, sf path is similar to san francisco but it's

available to those people who will be available for medi cal come january 1, 2014. the current 10 thousand enrollees were enrolled, they will be all the nautically enrolled in medi cal in january where the sf path program will end. these two programs, healthy san francisco and sf path have put san francisco well ahead of the health reform implementation curve compared to other states in the nation, healthy san francisco was created in 2007 and because of this long history we have of coordinating scare for the uninsured, we have largely add deed pent up demand, it is a spike in utilization that occurs when an uninsured person first gets access to health insurance. we've promoted the medical home model, our uninsured are already used to the medical

home, our managed care and which will be most prevalent under health reform. we have more providers in our community who are committed to serving our low-income population and more importantly, we know who and when are uninsured are for the most part, for 71% of our uninsured, we can send them a let e call them on the phone and text message them, we can tell them of the changes that are coming with health reform and help them enroll into health insurance, sf path has given us some experience to create a managed care environment because it is subject to all the rules as a managed care plan, we have documented the challenges to providing enrollment into federal programs and highlighted management care access strategies, approximately 2 thousand enroll lees will transfer without the need to apply. this graphic shows the

estimates of coverage transitions for healthy san francisco and sf path members under health reform. you'll see at the top, about 60 thousand members are currently enrolled in healthy san francisco or sf path, we estimate that about two-thirds of them, 40 thousand 500 will be eligible for some kind of health insurance. 28 thousand will be eligible for medi cal and 12 thousand 500 will be eligible for covered california, 19 thousand 500 will be ineligible for coverage, those will be the undocumented residents or people who have other reasons not being subject to the mandate. eligibility does not equal an enrollment and people will have to actively enroll into health insurance to get the coverage they are entitled to, so of the 40 thousand 500 we think are eligible, about 25 thousand will access insurance. this is based on a 62.5% rate of retention that we currently

experience in the healthy san francisco program, so we have anticipate hated our retention rate which is quite good for our program will translate into health insurance enrollment. this leaves about 15 thousand 500 who represent those who may be eligible but do not enroll in health insurance. and they might not enroll for any number of reasons, enrollment is complex, they may choose to pay the penalty rather than enroll in insurance, they may choose to pay the penalty rather than enroll in insurance, this group plus the 29% that are not already in sf path are the individuals we will have to focus our outreach efforts on. >> just a quick question. do you have any more specific information on the 35 thousand that you're talking about in terms of, you know, what that group looks like, any

demographics, ethnicity, lgbt or not, do you have a sense? >> we do, and i will -- 19 thousand 500 of them are largely going to be undocumented residents we anticipate. they may be other people who are not subject to the mandate because of hardship or other reasons but largely undocumented. the 15 thousand 500 will likely be those that are at the highly end of the healthy san francisco limit, it cares for people up to 500 % of poverty and those who are medi cal eligible will be able to apply to medi cal without no cost to thel, so that will be an easy decision, as the income gets higher, the cost sharing gets higher. >> what percentage will be lgbt? >> i do not have that percentage. >> thank you. >> within the department of public health, we really have a two-fold focus on health reform

implementation. first is about dph's own health care delivery system. we are looking to ready our system to be the provider of choice for our patients, our uninsured parents have not had a wide choice of health care providers but health insurance provides them with that choice, we want them to choose us. a recent survey indicated that 60% of low-income individuals who are uninsured would change their provider if they were given the choice to do so so we are responding to that challenge and integrating the service we offer throughout our delivery system so we do a better job to coordinate the care our patients need, we're working to improve quality and capacity to increase access to care, we're enhancing our patient's experience by shortening waiting times and increasing our efficiency in customer service and these are exactly the items that barbara is at the health department working on today. our second role is more citywide in nature and related

to our mission to protect and promote the health of all san franciscans, we're maximizing enrollment into the health insurance options under the nca and i'll focus on this a little bit more. the health department has identified several key factors to the successful implementation of the aca in san francisco. the first is personal responsibility, this is not just the requirement under the individual mandate but our civic duty to ensure we step forward and enroll in health insurance. i have a friend that says everyone in san francisco was born with a participatory governance card and we need to be mindful of our role in ensuring health reform's success. we also need to be mindful of how we discuss affordability in this context, it's not to discourage people in enrolling in health insurance, we need everyone to enroll. second we need to ensure

successful transitions of uninsured to health insurance, because we know who the majority of our uninsured are and how to contact them, thanks to healthy san francisco, we have several healthy san francisco initiatives under way to ensure this successful transition. i've been saying that healthy san francisco is now not only a health care access program but a coverage conversion program. we've been highlighting health reform messages and our participant newsletter, we have a website on information on health reform readiness, we're launching a text messaging campaign this summer for retention, we're training sf path s*us mer services to answer questions regarding health reform, we're spearheading a citywide campaign to ensure all healthy san francisco participants can apply for any insurance in which they're eligible at any of our 33 enrollment sites throughout the city and partnering with the human

service agency for communication and is staff training, behind the scenes, we're working to provide a smooth transition into medi cal. we need to do targeted out lao*efp to certain populations, and that's to the question you asked earlier, who are the uninsured who need the most outreach. san francisco applied for an education grant and was not awarded the grant due to our significant process in reaching out to our uninsured, it identified those special populations that are most likely to be uninsured and may require special outreach, young adults are critical to health reforms success, younger healthier people are critical to balance out the older who are often sicker and help keep costs down for the whole system and will eventually lower prices overall. latino and asian adults with a

specific focus on chinese adults, information from covered california will be available only in english and spanish and not chinese so this will require a local effort, residents of the southeast corridor and small business -- small proprietors and other businesses, the final is messaging, and this is the simple three step message that we've been saying all along, new opportunities for health insurance coverage are coming and we are here to help you. health insurance is better than healthy san francisco if you qualify for it, but if you don't qualify for it, healthy san francisco will be here to help you. so, the timing of these transitions, in june of 2013, cover california identified the five plans that will be offered in san francisco which i named earlier, in october of 2013 as the supervisor indicated earlier, open enrollment begins for medi cal and covered

california. in january of 2014, the sf paths program ends, the individual mandate begins and we transition 10 thousand people on that one day into medi cal. and then between january of 2014 and december of 2014 and really ongoing after that, about 25 to 40 thousand healthy san francisco participants will transition to the insurance for which they qualify. at this point, i will turn it over to noel sim mos to talk about implementation at sha. >> good afternoon, supervisor, noel simmons, deputy director at the human services agency, just to round out the picture of what city act sis are doing to prepare for health care reform, i have three slides to share with you about the efforts at sha, in many other jurs dictionary, the health and human services departments are separate, of course -- combined, of course here we're

separate to most folks don't understand that they have a mandated roll in implementing health care reform, we have four primary charges, the first is to conduct eligibility for medi cal and exchange tax credits, for customers who will be applying in person online by phone e-mail or fax, that's a responsibility that we have today, we'll be expanding to the new expanded eligibility and is the exchange population on october 1. secondly, to accept warm hand offs, when a client calls looking for coverage, they'll be screened by the state call center and if appears that they are likely to be medi cal eligible, those calls will be transferred to us at the county level to process those eligibility requirements. thirdly, providing ongoing case management for all medi cal programs which we do today, and

then finally enrolling customers into all programs for which they are eligible, by which i mean not just health coverage programs but over the long term, all other social services programs including cal fresh and calworks, this is a process that's known as horizontal integration, the affordable care act encouraged but did not mandate horizontal integration, the state of california has embraced that vision and it is the vision that we are holding front and center as we move forward with implementation. social service agencies including hsa are undergoing a culture change in anticipation of health care reform. the question is no longer whether a client is eligible for benefits but rather for what is a client eligible. we are moving as mentioned to a service center business model in which any worker will be able to handle any customer need and in which all doors will lead to coverage. our goal is to provide first class customer service and this

includes coordinating with other social service for which people may be eligible. we are currently engaged in hiring and training a number of new staff in ants pace of enrolling over 30 thousand new clients into health coverage beginning in october. we are transitioning to a service center environment which involves reworking all of our business processes and implementing a whole fleet of technology that is are intended to help our workers do their job more efficiency but to enhance the customer experience. we are conducting outreach to the new medi cal eligibles who are already on the hsa caseload, we know today we have 7 thousand or so county adult assistance program, ga recipients who are eligible for medi cal, 25 thousand additional ones will be likely to be eligible for medi cal, so we will be doing a lot of

concerted outreach through channels to those folks and we are doing a lot of coordination with stakeholders both inside the city, family and external to make sure we effectively transition healthy san francisco and path clients to medi cal into the exchange and make sure we do a lot of outreach to our target populations, that concludes the presentation, i know both colleen and i would be happy to answer questions. >> supervisor mar, any questions? >> i wanted to ask a couple of questions of our deputy director. my understanding is that mayor lee reinstituted the health council, and i wanted to know if you could talk a little bit about that, what the purpose or the role of the council will be going forward? >> yes, you're correct, the mayor announced this morning

the reconstitution of the universal health care council, it will be led by director goober see ya, it will look at aca implementation in san francisco to maximize enrollment into health insurance and we'll look at the intersection of the sca, we anticipate that it will be convened this summer and may run for a couple of months, two or three months. >> one of the things that has been speculated is that maybe the council will look at the issue of gaps and i was wondering if you could talk a little bit about that. >> that is true, to look at what our local ordinances cover, what the health care -- what the affordable care act covers and what gaps there might be based on local policies that have already been put into effect about our health care priorities where there might be opportunity tos fill those gaps.

>> i'm wondering if you can talk a little bit more about gaps, you know what we mean by gaps, i know there's been some issue at the state level with medi cal because of substantial cuts due to the budget crisis that the state has faced that has placed additional requirements on individuals, can you talk a little bit about that. >> i think you mentioned a couple of them earlier today, for example, the employer provisions of the aca start at 50fte's for large employers, the health care security ordinance covers employers down to 20fte's, as you mentioned, the asa pertain tos 30 -- fte's working 30 hours a week where ours look at them working 8 hours a week, affordability needs to be discuss ined this context. the 15 thousand 500 folks that

will remain uninsured and will choose not to enroll, some of those reasons may be unaffordability. >> will there be medi cal el jebl folks that will be impacted by costs as well? >> for the newly eligible, they will have no cost to medi cal, so they will have no premising and their cost sharing will be fairly minimal. >> and to the extent there's been some cost shifting under medi cal at the state, will that impact any individuals? >> i think the cost shifting at this state, it's been provides, california has very, very rates for providers, 59th in the nation, i believe, and that translates to access, so individual access to people for medi cal to the services they provide that they need, sorry. >> and just a cpl