mind the populations that were identified by the council and specifically people who were between 250 percent of poverty and employees of small business and part time employees. we are working to quantify the potential populations and estimate the level of need and assessing the financial and problematic feesbility of the solutions we agree with the intent of supervisor campos's legislation to increase the access to health insurance for the people that can qualify for it and address the issues of affordability and the barriers that may be in place for certain people and we are committed to addressing this issue. but we also feel that it is too early to create the parameters of the subsidy program that will prescribe the program design in statute. and we are at the beginning stages of implementation of the aca and we are just five months in and so we don't know what the market place is going to look like in the next year. and we need to understand that how the aca will effect all

stake holders and employers and employees and insurancers and there is still many moving parts and the employer mandate which is partially in effect for 2015 for large employers and not small and medium until 2016 and employer behavior is difficult to predict and how the employer behavior regarding the hcso are not available. and also, consumers have a steep learning curve and early experience suggests that a lack of understanding about the insurance, and healthcare cost and available options. and it could be another year or two before patterns begin to show how people are accessing and utilizing aca coverage, and it is also very complicated to set up a subsidy program like coverage san francisco and it requires a cautious approach and the due diligence on the department's part to be sure that it is effective for the individual and cost effective for the city. and the cost of health insurance as the supervisor

noted earlier falls into two primary buckets premium and out of pocket costs and so subsidizing premiums does not necessarily address all of the individual's healthcare affordability concerns and the plan rates and federal subsidies vary by a person's age and income and geographic location and as such, the age and distribution, in enrollees would effect the structure and cost and plan rates are expected to change from year to year and we have the information only on the 2014 plan year. we also want to be mindful of the financial implications for the city and once started as a subsidy program will create reliance on the ongoing monthly subsidy to make insurance affordable for individuals and while we think that this is a goal, we are mindful that this create a long term obligation that could continue for a person's lifetime. and we are also not entirely sure that dph will be able to administer such a program.

and there are certain restrictions about the steerage of the individuals and to the different health insurance and we hope to be a provider on coverage california and that could be a barrier in the future. >> if i may right now you have a plan administer a program that will allow the people who can't afford the aca to remain in healthy san francisco, how are you able to do that? >> we allow, we maintain eligibility for healthy san francisco for people who do not have health insurance otherwise, and otherwise meet the eligibility criteria. >> i don't understand the change in the administrative burden if you are doing what you are doing today, we are simply codifiing that you are going to do through the end of the year. >> as fars the changes to healthy san francisco go, that may be true, but the program is a different program and may require the administration of the individual subsidies to

individuals as opposed to access to the department's healthcare services. >> i guess the question is this, you know you have known the department of public health has known that the affordable care act is going to go into effect for quite some time, are you telling me that in 2014, the department of public health in san francisco is not ready to implement the affordable care act. >> i am not telling you that. >> what are you telling me. >> i am telling you that we are implementing the affordable care act and as the enrollment figures have shown, we have out paced our projections in enrollment and people in san francisco have more access to health insurance than they did before and those who don't have access, they continue to be eligible for healthy san francisco. >> well, i am still not clear, on what it is that is different about what is being proposed here. because you are still going to have to deal with the aca unless you are saying that you are not ready, and we are actually have been saying for quite some time by the way my

office urging the department of public health we actually have been held hearings because we were not seeing much action from the department of public health in terms of getting ready for the implementation. and so if that is where we are, the truth is that the department of public health is admitting that it is not ready for the aca, we should know that. >> that is not what i said supervisor. coverage san francisco is a different program. coverage san francisco is a subsidy program that requires the department to look at affordability of health insurance for individuals elible for coverage california, and makes subsidies to help to make that insurance affordable, i think that is a good idea to make insurance more affordable. but it is very complicated and not something that we want to enter into without having a lot of cautious thought, and analysis and study so that we do it right. once we do it, it is hard to undo something once you do it and we don't want to do it wrong. >> have you had no trial analysis done?

>> no actual analysis have been done. >> how long have you know that the aca is going into effect. >> the rates were not known until late 2014, or mid 2014, we did not know what the affordability issues would be. >> if the entire state of vermont and new york and massachusetts are doing it, san francisco has 850,000 residents. >> they are doing it through a state wide tax or other state funds and it is not clear that we have the ability to do it in the way that we are doing it now. >> so do you have any alternatives? >> we would suggest that we study this longer, we think that it really merits a thoughtful consideration of how to structure such a program, and i want to give you a case study of something that occurred in la. a better la is a non-profit group that has used private founds that pays for coverage california and individuals between 20 and 30,000 a year are elible for federal subsidies and a better la pays

for them to choose the bronze plan on the coverage california and paying their entire subsidy and the pilot began this year, and today the enrollment is 16 because out of pocket costs were considered too high for those individuals and even though the full cost of the premium is being paid for them. we think that this is a good example of why we need to put some thoughtful consideration into how we put together a program that will really help to address affordability. we are committed to addressing the issue of affordability and we are reluctant to have a program designed created in the statute at this time before we know more details. and you realize, right? that when you health and security ordinance was put into effect and it was passed unanimously a lot of the data was not known and you actually knew a lot less, then, that we know today. so, at the time, that the director of public health, mitch cats you know moved

forward with the program and made it happen, so what is different about today? >> director garcia is not willing to go into an ongoing subsidy program without knowing the financial implications in the long term, our department is projecting heavy reliance on the general fund in the coming years if we don't make course corrections to be more effective under the health reform which we are doing and we can't create another financial liability on top of that at this time. >> and i think that you know that we have offered to work with you and changing the legislation to make sure that there is no requirement additional requirement created under the department of public health and so we look forward to continuing to work with you. but could i ask you a question? one of the things that i was really impressed with the health and security ordinance and actually think that is one of the reasons why it was so successful was the hands-on involvement by the director of public health mitch cats.

now i have and i can't think of a more important hearing on healthcare that has happened in san francisco in the last few years, is there a reason why the director of public health is not here today? >> director garcia had a conflict that she could not decline and i am here on her behalf. >> that is unfortunate. okay. colleagues, any questions for the department of public health? >> yeah. >> excuse me. the presentation, thank you for your presentation. i wonder if you could give me some specifics. in regards to the workers currently using the healthcare, and the accounts, do you know how many there are?

of the health reimbursement accounts? >> yes. >> i may ask if the office of labor enforcement can answer the questions about that on reporting. >> workers, and which means the employee. and related to that question, would be how many are currently enrolled in the hsf through the employer contributions? >> i can answer the first question. >> sure. >> so according to the employer reporting forms for 2012, which is the last year for which we have published data it was

approximately 46,000 employees have access to hras. >> and they have access and how many are enrolled? >> donna, lef et and office of labor and enforcement i want to clarify that number 46,000 does not include the employees who have the city's medical reimbursement account. this is employers who have hras that are administered through third party administrators. and so, your second question is a different universe of people. >> and i can answer the second question. >> so the city, the department of public health operates the city option which includes two things the medical reimbursement and healthy san

francisco. 43,000 people, employees had contributions that were assigned to healthy san francisco, and approximately 57,000 people have a contributions that were assigned to medical reimbursement accounts. and just to clarify, in the existing structure that continues in the medical reimburse amount account funding could be used to purchase the insurance on the exchange. >> and then this is probably related to supervisor campos's questioning. did you have any idea how many of the workers would come and take advantage or would take advantage of coverage san francisco? >> we worked out at it a little bit backwards, we looked at the number of people who would remain uninsured and we thought that there would be about 37,000 people who might be

eligible for some kind of subsidy for coverage california. >> then i know that you mentioned, you have not had really had time to look at what the design might look like. and to dig deep into it. but, in regards to a preliminary type of vision, do you have knowing that this legislation is coming down, have you developed the first steps of this thinking? >> we have looked at many aspects of it definitely looking at what constitutes affordability and what goes into the cost of health insurance and how those can be and how such a program would be structured but we don't feel confident that this is the right mechanism at this moment that our thoughts are involved in this moment. >> and you mentioned it again, and you know, just complicated

and so forth, but could you be just a little bit more specific in terms of what the challenges really are. >> certainly, i think that the mechanism that we tried to look at how to create some kind of a subsidy mechanism that would be compliant with the ordinance that is before you today. but, what is complicated is the financial implications of that program and we wanted to make sure that a subsidy that was provided was sufficient to make sure that it made the health insurance more affordable for them and because of the complicating factors of the difference in cost of insurance, based on age or a family size and that the change in rates, we really didn't know what would happen after year one or year two or year three and so really, trying to understand the trends so that we can do a financial analysis is really where we need additional information.

>> could you and what are you talking about, and it seems like the one, the way that you are looking at it in the program design is that it would be set up in the way that it would be some subsidies, that can go on forever. and if it goes up with the price of the medical expenses, and that is one way to look at it. and i am wondering if one can look at a program that is limited to the resources that is available. rather than, thinking in terms of the availablible resources currently under the hsf? and having to use it for the general funds. >> you are saying if there were x-number of contributions already to that dividing that level of contribution among the eligible participants in order to make subsidies? >> right. >> we did talk about that too.

and what we don't know though is whether that would yield subsidies that were effective enough to make health insurance more affordable. and so if i think about the better way la, example, even though the premium costs were covered the out of pocket costs were so high that they no longer participated in the program and so we want to make sure that we are buying at the right level of the plan for the person that they need and the right amount of cost sharing to help them to make it affordable and i just we don't have the information to dot analysis to make sure that the funding that comes in would be sufficient to do that. the mechanism that we have now is really through the medical reimbursement account where the contribution made by the employer on the employee's behalf is used directly to purchase the health insurance. >> and but at what point would

you actually have necessary data? >> i think that we would need at least the first year of aca implementation to analyze and that will not be available until mid 2015. to show the experience early to the made 2015 to show the experience and the time to use the data to develop a program i would say 18 to 24 months. okay, thank you. >> supervisor mar. and just we have a quick question because i want to open it up to public comment. so, you know we have preliminary numbers from the office of labor standards and enforcement for the 2013 calendar year. in terms of the rate, of reimbursement and these hra accounts. and again, it shows that of the 124 million dollars, only 30 million actually was used for healthcare, which means that 75 percent that is not. and so do you have any reason

to question those numbers? do you feel that that is accurate? >> i don't have any reason to question, i would just say that those numbers reflect a year that is prior to the changes that were implemented by the aca and so those, that rate of expenditure is consistent with the previous rates of expenditure and i suspect in 2014 it may be different because the mechanism is no longer available to employers. >> and you mean that you could actually see that there would be more use under an accepted benefit hra than hra? >> no i was meaning that employers would likely have to choose another option because a full 40 hours of an employee's contribution could no longer be attributed to an hra and since the accepted benefits are limited to 20 hours. >> okay. could i ask just a final question. >> certainly. >> what is the department of public health have a message

for the 26,000 workers and their families that have not had access to insurance all of these years. >> i would say that healthy san francisco will continue to be available to for them and those with medical reimbursement accounts can use those funds to purchase the health insurance on the he can change. >> but again, the hra money is not going to be available for them to buy insurance. >> the medical rebuserment accounts the mra funds. >> what about the employers that are using the hra. >> so as i mentioned the hra are accepted benefit and so they are limited to 20 hours per week, and i could let olsc describe that but the remainder would have to be made in another way and if that were made to the city option, we would put that funding into medical reimbursement accounts. >> does the department of health have any concerns that 26,000 workers are going to be able to buy nice glass and not be able to go to a primary care

physician. >> they are able to go to a primary care physician, in the healthy san francisco program. >> so you want the tax payers to continue to step in and fulfill the obligations that should be fulfilled by the employers. >> that is not what i said, sir. >> okay. >> well, i think that the presentation from the department of public health speaks for itself. and unfortunately, the level of readiness for purposes of aca implementation is not where it needs to be but we will get to that point. and let me call on public comment. i would like to begin with cecilia tran who is here on behalf of family member tom meano and you each have two minutes. and i usually give three minutes, but we might lose a quorum given the number of people that are here, i apologize for limiting it to

two, tim paulson and merrill boyce, dave mego, dina long. ron silver citying. monica and if you don't mind lining up on our right your left. >> go ahead. >> thank you. >> i am with the assembly member who wishs that he could be here and he was not in sacramento he would be here right now. the goal when the assembly member introduced the healthcare ordinance as a supervisor was very simple it was to make sure that every san franciscan had access to healthcare. and then the intent of the ordinance was to take away as many barriers as possible. over the years, we have seen that the city has become a model for making care available, but there is still obviously much work to do and we are glad that supervisor campos is here to carry on the original vision of the ordinance. and it has become very clear

that there are still some changes that need to be made to preserve that original vision. firstly, it is important to make sure that the employer contributions benefit the employees as intended. there have been attempt to get around this, and the legislation that handled and make sure that those employer dollars will be used to truly help the people get access to healthcare and secondly when coverage california took effect, we found that some people are falling through the cracks and were unable to afford insurance, and it looked at, that they might be denied care under healthy sf also and compass ordinance would take care that have and creating a much needed safety net for those who were already being pushed out of the city by the on going affordability crisis. >> and so, to put it very, very simply, the city has a great opportunity here, and making sure that everyone health needs are met and benefits all of us, and there is no good reason to

pass this legislation. i am sorry, i was making sure that everyone was paying attention and they are, thank you. >> tim paulson and i am the executive director of the san francisco labor council and the labor council as well as the rest of the healthcare coalition, strongly support this legislation, that being said, you know we are proud of the both of the affordable care act for coming into effect and the fact that the hel healthy san francisco and the ordinance that we fought so hard for with the supervisor amiano became the lay of the land and i was involved in all of the negotiations that were taking place with the mayor's office after this past eleven to nothing and i think that it was brought up today and i am thank you, supervisor campos for mentioning this that we were ready to rock and roll and there was resistance because of the political context and we

have already had that political discussion six or seven years ago over this act and i think that to have it come up again is you know, sort of a little bit ridiculous. and we do have and i was a member of the mayor's healthcare committee and the one thing that did come out of that committee was very clear. and that is the affordable care act, and the san francisco healthcare security ordinance can exist side by side. and there is absolutely no way that anybody can or should be able to argue against the path of this legislation takes and we do have the health savings accounts right now where the people are clawing back the money and we think that with these accepted benefits the loophole is actually worse, it is much worse and there are tens of millions of dollars every year that are supposed to be going into some type of a healthcare for the workers who qualify, under the san francisco healthcare security ordinance, that are not. and we do not need to wait any longer, and there is plenty of

data that says that this money is being clawed back and we really want to do what san francisco has stood up for leading the nation in healthcare and make sure that this is fully enforced and that the money does go into healthcare and we fully support this. >> i think that supervisor mar had a question for you. >> i just wanted to ask, miss cowa brought up los angeles model which she said a non-profit called a better la, i think that you are referring to i think that it a chamber of commerce created a better la, but i am wondering if various health equity and labor groups in los angeles have supported that model or if it is purely driven by the chamber and larger businesses in the city, do you know? >> i don't know that very specifically. i do know very much though that the counter part in los angeles who has been following what we are doing up here fully supports that. i am not fully aware of the model that was brought up

earlier. >> thank you. >> next speaker. >> good morning, i am merrill vice i am the director of healthcare coverage and access and last fall i had the pleasure and privilege to become a trainer for coverage california when the state could not get everybody trained to help to enroll and so we ran training sessions and trained over 115 enrollment counselors and 80 from the department of public health staff and 35 in the clinics. and bh we got to the part in the training where we discussed the cost of the premiums and the co-pays, eyes out and hands in the air and other people could not restrain themselves and gapsed. and there was universal agreement from the staff and that this is not affordable, people who have been on hely san francisco and using the clinics across the city, are

not going to be able to afford this. there was a lot of disappointment in the room and people were excited to help the people sign up for coverage california. and these staff, are wonderful people and they have worked with these families since 2007 when it first started and then they were disdrought i mean i had one person grab me and tell me that i want tell people this, i want them to have full scope insurance, hsf is wonderful but this is going to be out of their reach. and so, they knew back in october that this was not affordable. i received a large number of phone calls from individuals across the city. sorry. >> and you still have... >> okay. asking for assistance, one fellow told me that i had been laid off and his wife had a job and didn't have insurance and he said well there is just no way, we can cut our food budget and then we can get the cheapest plan and then we

cannot afford to use the services and we can do it this year because we are not signing up until the end of the year we can't do it every month and so we can be insured for a few months a year we can't afford it will not work the premiums are too high and then the co-pays are too high. >> thank you. >> i am going to read a few more names, ian lewis, dennis kelley, sid c. barbara, sasana roma guy. >> good morning, i am executive director of the kurry senior center and we are a public private health center with the department of public health and also the board president of the clinic and a couple of comments and one is aca is working on the ground for health. and meaning that we are serving more people there, based on the plan that we have done a couple of years ago and we are really doing good and this is the health department and the clinics on how we have changed healthcare and i add this because we don't often hear that we hear about access and cost. the work and the healthcare is going well. and i am here to support one

part of your ordinance which is about extending hsf healthy san francisco for people passed the age of 65 and those eligible and uneligible for medicare will not get healthy san francisco. and as well, and so what you have is about 7,000 seniors in san francisco who will lose their hsf and assumption was you are going to get medicare and but you are not. so we have people that are going into our clinics that have getting health san francisco and seeing the same doctor and that fair family is told no you can't. so part of your legislation, extends that and so i am here in support of that part of your legislation, and thank you. >> thank you, next speaker, please? >> good morning, supervisors, jim, and san francisco chamber of commerce who also served on the universal healthcare task force as well as mayor's task force in 2006. i want to first say that in spite of the political nature of all of this, we don't

believe that there was an unknown loophole in the legislation that was enacted 11 to nothing by the board of supervisors in 2006. small businesses especially need options, and in fact, federal law requires options for employers. and using health reimbursement accounts has been an option that is available, that has allowed many, many of the businesses to survive, that might otherwise not only not be able to expand but would fold because of the huge cost for some low profit margin businesses. and but, i think that this legislation, before us today, is not ready to go forward to the board or to the mayor. and i met with supervisor campos, months ago and i urged that a broad coalition be put together, as was done in 2006, specifically, unlike the task force last year of the health department, and specifically, to look at legislation