from the aca, so in san francisco we see the second highest percentage of people enrolling in minimum coverage throughout the state. and the other two regions are in the central valley, where presumably more people might be eligible for exemptions and as more data becomes available from coverage california, we are hoping to see what might be going on here. and most of the other regions have right around 5:00 percent. and the unsubsidized group and the commercial insurancers take a bigger piece of the pie than the chinese health plan. so we previously presented an estimate of the residually uninsured and we needed people who will stay uninsured after the first year of the aca implementation and in order to to better align those estimates with our city enrollment projections and the fact that 100 percent of the path

population has transitioned and that we have granted an extension to the healthy san francisco participants to be able to stay in the program through the end of this year. and we updated these numbers. and so in this in this respect we have 87,000 uninsured and 18 to 64 and of those, most of them are in our healthy san francisco or in the sf path programs and whereas there are almost 28,000 who are unknown for our systems and so, when we tried to determine who was eligible and in those groups we find that in both groups, most of the people are eligible for medical or for subsidized on coverage california. but, combined, we have about 18,000 people who are not eligible for coverage. and first we are due to the undocument status that it was also included and because of this case, we classified eligibility as subsidy and so that some people who are not eligible for subsidies or they

are not eligible by age. >> and so, we know that everyone who is eligible did not enroll, and so at the end by applying estimate and different scenarios who is likely to enroll and not, we come up with on the left, among the unknown population that more than half of them are not going to enroll. and this would likely be because this population did not really take an initiative to enroll in the coverage when they had, or to enroll in healthy san francisco when they had the option or so they might not know about it. and on the right, we have we have more than half of the hsf and the sf path association likely to enroll and over all when you combine them for the gray boxes and so that the people who are not eligible for the aca and those who are eligible and may not enroll for whatever reason, and will come up with 43,000 to 52,000 people.

and it will stay uninsured at the end of this year and we expect to update these numbers for 2015 as we get more trend data coming through this following year. >> so, to out reach to all of those people who are not signing up, i will turn this over. >> hi, as she mentioned last night ended the coverage california open enrollment period. yesterday by two p.m., there were about 324,000 unique visits to the fight along. and so individuals who are unable to start an on-line application or complete an on-line application, due to technical difficulties, and will be given until april 15th to actually select a plan for coverage on may first, and provided the payment is made.

>> the next open enrollment period will start in november of this year. and for coverage beginning in 2015. and there are some opportunities for enrolling outside of the open enrollment period which are qualifying life events, for example if you are married or get married, or divorced or have a child, if you permanently move from one area to a different area, that has other health plan options, if you lose other healthcare coverage such as medical or other coverage or if you experience a change in income that will effect your eligibility for a financial assistance. >> and then, just a couple of updates on out reach activities related to dph. and dph and have to say that they had the first meeting with the sheriff in march. and the sheriff is planning on potentially partnering with the community based organizations, to assist with the enrollment

with the enrollment of inmates prior to their release. and he is also considering training more than 20 of his staff, and in the local on-line enrollment systems for medical and healthy san francisco. and since january, approximately 325 applications have been submitted from medical. and on march 22nd, healthy san francisco had their enrollment event that san francisco city college to assist individuals with the enrollment and to health insurance. and 200, to 300 people were expected to attend and more than 223 individuals attended. and 72 applications were completed and 41 of those were for coverage california and 31 of those were for medical and 31 were initiated but not completed. this was made possible due to the partnerships with many organizations who provided the

volunteers and staff time to support this event. and now that the coverage california enrollment period has come to an end, this city will be looking at ways to target medical population as a medical enrollment is year round. >> so, we are happy to answer any questions that you may have and i thought that it was probably worth mentioning the article that was in the paper today, about healthy san francisco, it is important to note that healthy san francisco eligibility has not changed since we started the program, healthy san francisco has always been available for the people who are not eligible for other publicly subsidized health insurance and uninsured folks who are not eligible for those programs and that includes medical, medicare and subsidies on the exchange. and we did as the commission know and extend the eligible for healthy san francisco through 2014 just for those

people eligible for subsidized health insurance on coverage california and the actual program requirements remain the same, supervisor campos is introducing legislation today to make the changes to the healthcare security ordinance that will propose the changes to healthy san francisco and the city option under the current healthcare security ordinance and we have yet to do an indepth analysis of the ordinance to determine what the impact would be on our budget and on our programming and our policies and on our operationalization of the programs that are envisioned. so we will be doing that and bringing that back to you. >> okay. >> and i just want to pull up and let commissioners know that this will be continued item and that we are planning to have this as a continuing agenda

item, on the finance and planning committee and we will probably come back to the full commission to give updates you know like on the more periodic basis when we have more aggregates and more concrete data, perhaps, three months to six months and depends on how this continues to evolve. and with that i actually have a couple of questions. and first question that i have is would we be able to track the data on how many young adults enrolled in the systems and i think that is also one of the priorities, you know, like for the affordable care act, is to really look at the populations that have historically under uninsured, and but would have the ability, you know, to get covered. >> and so i suspect that coverage california will provide some break down at some

point of the population that enrolled during this open enrollment period. and i don't know if data is available by age now, is it by age now? >> occasionally they report the data broken down by age, so they have a group for 18 to 34. and so, we anticipate that they will make that available when they are a little less busy. >> okay. >> and the second question that i have is pretty much like a follow up question, from the commission meeting last time because we just got information that when i might part d would be eliminated and that the budget would float into the part c, and because at the same time we have medical, expansion here, and under sf path and also under affordable care act,

and under our california jurisdiction, i am curious, like how that transition takes place. because it is effect different part of our budget. >> i am not personally familiar with the part c and part d of ryan white but i will tell you that the extension of healthy san francisco to the end of december actually first began with the people living with hiv. and there was concern that the individuals who were on healthy san francisco who have to transition to health insurance would have to change providers, and if particularly if they were eligible for coverage california. and the department of public health not being a provider on coverage california, they were not able to keep the provider with the department of public health and other healthy san francisco providers and so at least for 2014, and people eligible for healthy san francisco, or i am sorry, people elible for coverage california in healthy san francisco including hiv will not have to change providers and that will give us time to look at the impact of the

transition of d into c to see how that will impact them before we make the changes to that population. >> i just want to note that there was any public comment at this point and we will go on to the commission comments. >> i have not received any at this time. >> commissioner karshmer? >> so i have a question about the jail, when you leave the jail is that one of those life qualifying events? >> yes. >> open enrollment any time. >> yes. >> have you said that... >> true, i believe that is true. >> that is an ongoing opportunity to enroll people when they leave the jail. and you mentioned the sheriff said that he was considering doing this and considering, are we going to have an update on when that might be decided n >> the legislation is at the board to give the sheriff the authority to enroll the inmates on their behave within the jails, the health department through the jail health is the entity that has been doing the inrollment and the applications that have been accepted have been through the jail health

staff and so they are working closely with the sheriff in order to figure out the best model and as they mentioned is what they are anticipating is that they will bring in an expert who has maybe, health right rkts 360 or some other one who has experience working with the inmate population and also, who has experience doing enrollment to help expedite that. also because, there is only so much information that you can take while the person is in the jail, and there is usually follow up that is required outside of the jail and the sheriff's ability to do that outside of the jail is more limited. and so the partnership with the cbo will be a great remedy for that situation so we can definitely report back to you. >> thank you, i appreciate that. >> commissioner sanchez? >> yes. >> and yeah, i would just like to ask if given the fact that there is any immediate focus on

the period now and between april 15th. and it has, or it has completed part of the computer, or are getting additional information that they have been required to get. and others who have had the navigation problems, and just spending many hours either on the phone and or waiting for some contact to complete. and i guess what i am saying, is that i know that in some counties, they are saying that here are the areas that you could contact to make sure that you complete the application, by the deadline, which is an extension period for california. and you know, i wondered in fact if we have those types of links let's say go to the nine supervisor districts in the city saying that here are two or three areas where there could be human technical assistance and not just a phone, and or a computer.

the senior seniors and no. and we could if we could disseminate this and i really think that it might improve the completing process especially given the multiculture and languages in the city, and so this way, that it could help them finish this particular complex protocol that has been for many of them and it is so important that they are lining up and concerned about it. i would hope that we could have some excellent desemination. and they will be able to help them to complete the process where they will be getting the additional tax information or updating this or making sure that everything is correct. and you understand that, because some are a little

threatened saying that well, suppose that i put something down, and i will be guilty of something. >> and suppose that i didn't have, but now i am working part time, does that mean and all of these questions, and i think that are brewing and we want to make sure that they complete the process to insure that they have adequate healthcare and so i would hope that we might have this in the radar and we could help our non-profit and those involved who really complete this process, which we feel is very important. >> and that is a very good point and there are many dph partners and all of the healthy san francisco sign up sites are also doing enrollment and we can get the word out that way, and there are many in san francisco that are focusing on this that we could work through. >> thank you. >> also, this is an educational experience. because this is the first time that that we have to do this kind of city wide enrollment

and just a little bit cautious that maybe you know, the next two weeks should not be our final target that really looked at the lessons learned and because the next enrollment period that is only like 8 months away and that might be actually and it might be a time line to look at what the gaps are and start preparing for that. >> very good point, thank you. >> i was just going to follow up on dr. sanchez's issue. and well we have a lot of cbos helping with the enrollment and all i thought that part of the message was that we have the two weeks to actually follow up to make sure that was done, and that is, so, is that actually part of the program? that we have asked our cbos is our enenrollment to work with

that public that had complete applications. >> it has not been done to date and that news just came out and so it is not something that we have acted on but we can certainly do that. >> we will look at it. >> thank you. >> and in terms of the, oh,, you have a further comment? >> sure. >> commissioner. >> hello, and director of san francisco, we did send out a notice this morning to all of the san francisco medical homes and it went out to all of the centers, and to let them know that please, that the circumstances have until april 15th, so that went out this morning. >> and that will be the publicity as well and thank you for that update. >> that was dena lawn, whispered to me that the member clinics are also doing the same thing. >> and that is the current

response and talk about the current response and the new legislation that you just spoke to, and obviously, it requires some time to do the analysis. and sometimes, it might also be unintended consequences, and i was going to ask, when we might be reviewing working together because it is partly an answer to the affordable question that we posed. several months or several weeks ago when we in fact agreed that we would extend healthy san francisco that you had indicated for those who were eligible for coverage california. and did not feel that it was affordable. and i was going to ask director garcia this is again, just immediately being introduced today, as to how we will be working with the initiative and with the mayor's office. >> we are already working with the mayor's office and we will also be working with campos's office to insure that we have

ample time to look at the consequences of the legislation, as it impacts healthy san francisco particularly, and also, our ability to implement, i think, some important programs in the time period that is being legislated. so, we are trying to work on that and tomorrow morning we will be spending some time on it and trying to get to the supervisor's office as soon as possible. and again, coordinating with the mayor's office on that as well. >> and if we have received the memo. >> we sent it out through your secretary regarding just a review of the legislation. and some of the time line concerns, and we have not and we are working on the financial piece of it as well as the implementation of the program. the programs because there are three distinct programs that are being impacted. >> okay. any further questions, commissioners? >> all right. question. >> i would just like to thank the chair of the finance committee to bring the matter before the full commission, i

think that this is a very important part that the commission is very much interested and i really thank you for bringing it to the discussion today. >> thank you, commissioner, and it was because this is such a like, brand new, system that we are like trying to help enroll people in, and now that we are open access, and it would be a great opportunity to, you know, like to send the message out to a different media. >> yeah. >> and i think that this shows how dynamic the process is, and not only are we dynamickly enrolling, over these periods of time, but the people who are coming in with the suggestions and how to answer the affordable issue. and that i think not only that we face, but the country faces if we were hoping to have the solutions before the rest of the country. >> yes, commissioner? >> just a word of caution not necessarily for the department

of public health, but hopefully working with our elected officials to insure that things don't get done too quickly, so that we live with issues that may effect us for the long term. and especially when it comes to financial issues. and we cannot afford to pass legislation in a way that it may be too quick, without really thinking how is going to effect us all. >> thank you. any further comments, and it is an important subject and so i am willing to accept the additional comments. >> we can call to the next item. >> item 6 is the consent calendar and i believe that he went through and described what was on there. >> right, it is before us as usual, if anyone wants to pull anything off of the consent calendar, we can have further discussion, otherwise the three items before us, on item 6, and

it has been moved by the committee. and comments on the consent calendar, if not we are ready for the vote. all of those in favor. >> aye. >> aye. >> all of those opposed? it has been passed next item. >> 7 is an update on transgender health project. dr. barry zevin. thank you for giving me an update on the transgender project oh, boy i get to control, oh, great. and so, just a little bit of history and then i will talk about where we are now, and where we hope to go and in the near

future. and prior to 1993, the department of public health was involved in transgender healthcare, and i would say that at that time, there was a conventional model that was focused on mental healthcare, and assessing patients in terms of stability. and many of the transgender people in our community did not get healthcare at that time. and many of them saw untrained doctors or were buying hormones on the street. and in 1993 was the origin of tom model transgender tuesday and soon after that, the origin of dimensions clinic for youth as well as the continuing of the services, on a small scale especially service and behavior health, and all of the services

that were delivered at that time were informed by sfdph policies, and things like any doors is the right door and our policy on harm reduction, and what we are able to implement, and was, an approach with integrated care, and that really looked like the primary care medical home model. and we have goals through that time, where providing access of healthcare to under served populations and very strong focus on hiv prevention and facilitating treatment for hiv and other conditions when they were occurring in transgender people. advantages to this approach were that we were able to provide culturally competent healthcare to the community and our patients had a high acceptance of this and we had much less use of black market

hormones and much less unmonitored hormone use and at least from our statistics less psychiatric decompensation of these patients once they have access to the medically necessary hormones and the high patient satisfaction with the gender related issues from the challenges, for us, prior to 2010, we continued to get reports of discrimination in our healthcare system, several reports of widespread discrimination. we continued to hear about access and quality of care issues. and in the limited number of specialty settings. and access to transgender surgery was very limited. and our response to those challenges a commitment to comprehensive and ininclusive training, and mandatory transgender 101 training for everyone in the department of public health who has any

contact with patients. and recent advancing that requirement for training, to all of our contractors as well. and a very strong uptick in that training. and in 2010, and we were able to establish the transgender program and the goals of that program is to improve the healthcare across the department to improve access to the transgender surgery and we were able to do this, without any additional budget funding by redeploying the staff and the use of mental health services act funding. >> and in terms of expanding access to transgender surgery and just through the 1990s and the early part of 2000 very few

poor people had access to any type of srs and during that period of time, at least for the past eight or nine years, medical has considered sex reassignment surgery medically necessary, but since the private surgeons would not accept the low fees offered by medical we did not have access for those patients. some changes that increased accessibility in 2010, medical changed to a predominantly manage care model and the cost saving measure and an unanticipated part of that is was the entities for providing the services including transgender healthcare including hormone therapy and surgery. and in 2011, members of the community approached sfdph about providing sex reassignment surgery for uninsured indegent individuals and advocates reached out to

the politicians and influential people in the community, and the city and county agreed to fund an srs program for uninsured people and the health commission was highly supportive of this and also in 2012, two surgeons moved into the bay area, offering srs in the practices which was a great expansion of services locally. last year, a medical managed care clarified their position. and on the coverage for transgender services and offered a letter to all of the plans in the state saying that medically necessary services needed to be covered and would be as defined in the international guidelines put forward by them in the standards of care. >> and 2013, we are all established our transgender health program, and looked at an established guidelines for

the department of public health, in terms of policy and procedures across the department, and initiated an ininclusive planning process within the dph and in the community, as far as how would we effectively expand transgender surgery? >> some challenges to that, doing a needs assessment has been difficult and we don't have good numbers in terms of the number of transgender people in the community and the number of those people who might want srs. and we were able to make some estimates. and we also had challenges in terms of these are scarce and all of our healthcare is scarce resources and the political process determined how these funds would be spent within the public health. the question of and challenge of whether or not the people would come to san francisco

specifically for this service, and had a manage that. became a challenge. and some key decisions and i won't make anyone read through the small print but i will point to it and a few of our ski decisions and we have established a community advisory board for our transgender health project, and we have created a transgender health portal within the san francisco dph, website, and which is kept updated with the current information for the potential clients for the people who are patients in the system and for providers through the system and that is kept updated with the resources and with the current policies. we decided that the criteria for uninsured patients for surgery would be the same as the criteria by the san francisco healthcare plan and we work closely with the san francisco he