with this population, it seems often times as individuals, the different indicators for everyone, it's different. if some people, it's confounded by homelessness, lack of family connections there's a lot of different things that we can try to quantify. but what we were try to go do is conceptually capture this group of people that typically do not get treatment until they hit what is referred to as a 51/50 until their disease grows to a great disability and they lose their civil liberties and taken to psychiatric emergency. what we're try to go say, who are these folks that are just almost there, so we're doing good at prevention on the front end and we're helping people manage their illness,

but there's some people who are falling through the cracks. we want to stop waiting for them to hit that grave of disability, so in that graphic, that's how we identified that point. it wasn't by numbers. it was by -- it was -- how do we reach these people? we've been -- we're challenged finding them too and when you look on the street, when family members call and they say, please come help us. they might be conserved already, they might be apart of treatment, they might not. we don't have the data on these folks. a lot of them are -- they're touching the criminal justice system , so we want to put together a case history of these individuals so we can describe them and put together better case plans so that we're not just engaging them but we're able to follow them through the course of their recovery which could be two years, three years or one week, who knows, but we want to identify this population better, but right

now we can't. that graphic is conceptual representation. if we can plug numbers in, it would be great, so what we do know is we have 30,000 people in our behavior system. we know that at any given type, we have 750 people conserved. those are two hard numbers we do have. there's a lot of in between there. and for us to be able to slice that out and put names to that is something, legally we can't do, but even within the department wee unable to do that. >> just to add another number, we have 300 to 400 people that's not really stabilized but in our emergency areas being picked up by ambulance. when you think about those numbers, i think about that group and we may see the population we're talking about in terms of people who not only have

substance abuse and mental health issues but could have physical issues as well. we'll learn as we do this implementation to identify that and keep the commission appraised of that in terms of the numbers. the majority of our clients are stable and are attending to their care and be have lots of programs to assist them and we're try to go do that earlier and earlier in their need. >> commissioner malara. >> i'm curious because you're dealing with people with high level of health care -- i mean, physical health issues as well, and the task force didn't include any hospitals or clinics. was there a reason behind it? >> we had stakeholders there that ran services and folks that -- >> you know the public -- other

hospitals, you know, have high usage of their emergency rooms by dispopulation and it would be great to have their input. >> it's not too late for lonnie and the chairs to have those discussions. i've had plenty of discussions with the emergency and trying to implement those in the past, so we can work through the hospital council on and they have a whole discharge group, so with that, we'll go out and search for that mogs and get engaged with those individuals so it might have been an over sight on our part, but -- but i have to do 40 people task force and this was how many members? >> 21. >> so we will definitely circle around the hospital council and they have an opportunity for input. >> that brings to mind that

there is at the medical society, i think an a psychiatric committee that has been quite interested in the past. we can check again with steve if that is true. >> part of this care group is not to stop the work, but to continue to do this work and to continue engage with our partners and we will continue to do that in this department. >> so commissioners, any further comments that we're prepared for someone to then move the resolution. >> i move that we accept the resolution as written. >> i second. >> okay. any further comments on the resolution itself? if not, then we're prepared for the vote. all those who are in favor the resolution before you, please say aye. >> aye. in all opposed. there's no opposition. the resolution has passed. thank you very much, and we thank the task force its work. >> i'll be pestering you on

the data piece. >> the next item is the san francisco -- the department of public health review of proposed amendment to the security ordinance and i'm hoping that the slide protector didn't go to sleep. >> good afternoon, commissioners. i'm the director and planning

and i'm here to provide information to the security commission to you today. so the owed nance was introduced my -- the ordinance was introduced by campos on april 2014 and it needs two changes to the existing health care ordinance. it requires employer health care expenditures to be refbable and it replaces the city option with a health care access assistance program and the implementation gate is -- the implementation date is october 14. >> i have two slides to show how the owed nance works now and how it will work under the proposed ordinance. at the dark box on the left that says "health change security law." that's the can't law. it

has two components. if we follow at the top, for the entities with 20 or more employees are non profit entities, and those are the thresholds. those are contributions that the employees must make to offset the expenditures. employees can make expenditures in a variety of ways. the first and the one in the middle is by far the most, it's health insurance. 88 percent of the employees comply with the ordinance and to the right, it's integrated health reimbursement account. those are referred to hra's. prior to january 1, 2014, those accounts were allowable and could reimburse for certain medical expenses and then upon 24

months of inactivity, the money will revet to the balance. they don't meet minimum coverage under the action ca -- what's allowed is those linked up with health insurance. those that cover accepted benefits, those that are accepted out of the minimum like dental and vision that don't comes with your health insurance. it comprises of two things. medical reimbursement accounts and those are operated by the city that monitors like an hra but operated by the city and healthy san francisco. so if a

person is eligible right now for healthy san francisco, they're routed into healthy san francisco and if they are not eligible for healthy san francisco, they don't live in san francisco for example, they work here but at the don't live here, then it twos to a reimbursements act. this is how it works today. starting at the blue box on the left, the health care security ordinance will have two programs like it has now. i put a darker color, the programs that are new to the ordinance under the proposed amendment. the spending equipment works the same with one key difference. i mentioned earlier that the health reimburse, those goes to the employer after 24 months, and the proposed amendments would make

those expenditures would say the expenditures are valid under the health care security ordinance. that's the only change to the top part. and then it replaces the city option with the health care access assistance program. and i had said to you a moment ago, there were two elements of the city option, reimbursement accounts and healthy san francisco. this adds a third option called covered san francisco. covered san francisco would make financial payments -- financial sub sidies to those eligible for insurance covered on california to make it more affordable. three options under the newly named health care rather than two. >> i'll go over each of these and the changes made to these.

the three elements of the health care access program one at a time. covered san francisco would cover the insurance under california. it would be available for those employees that have health care expenditures made on their behalf. dph will cover with california to make this program as easy on participants and the city as possible. and or other funds made available by the board allocated at the discretion of dph on received as grants and the program would be designed to have enrollment to maximize affordability and taking

account the cost and other cost sharing. the ordinance -- it would change the income eligibility, it goes up to the poverty level and this would adjust it to 400 percent of the the poverty level which is a level that's consistent with the subsidies offer under covered california. in order to be eligible for healthy san francisco accident you would be ineligible for public insurance on subsidies in california. and others -- and finally those who don't have an offer of affordable insurance by the department of public haelts.

the third element is the health care acts and these are the same as the medical reimbursement accounts and they'll be able if people who don't qualify are if healthy san francisco or covered san francisco. this program designed and proposed legislation is consistent with the work of the universal health care council. the health commission passed a resolution supporting the report and the findings in the report. you see here the guiding principals that were adopted by the universal health care adopting the health care out and maintaining healthy san francisco, addressing affordability and shared responsibility among all stake hold stakeholders in the

policy. the first policy was the health care security remained in attack. they were not in conflict with one another and the second was some populations would still face challenges finding afford insurance as to the cost of living in san francisco. >> the department of public health has implemented the health care suggestions. health care san francisco was expanded and health reform is confusing for a lot of people. there was a window to where people can enroll. this are were care issues so we extended care san francisco. we have outreach to account holders during open enrollment people. because we control these accounts, we know how much each person has in their account and we're able to send

them a letter highlighting they can use this account balance to purchase haelts insurance on the exchange. we analyze on have been ongoing analyzing the affordable of health care and access in the san francisco context looking at affordability in san francisco, cost of the living in san francisco compared to other places. we've been trying to quantify the potential populations that would require assistant under such a program of covered san francisco and trying to estimate the level of need, and assessing the financial and programs of solutions. any solution we implement has to be sustainability for the department of public health in the long run and financially feasible. we believe that the department of public health needs to have flexibility to effectively

and efficiently maximize affordability of health insurance for individuals. the cost if covered san francisco hasn't been determined. it's a complex matter. the cost of health insurance is going to change every year, premiums are going to change every year. the cost changes by age, by family size, by income depending on whether people get a subsidi or do not get a subsidi. it may be different for a healthy persons verses an older person who has health care needs. we want to do this carefully. it was addressed in the health care council, about -- but we want to do it careful. it needs to be sustainable for the city, so the cost hasn't been determined and we need to do that before we can make sure it's a program that the city can afford in the long term. it's a matter of giving a person a monthly

subsidy for a long period of time and creating that is something we want to do so thoughtfully. also ac implementation is five months in. a full implementation with many parts. the mandate was extended and extended again and there's discussion about whether it's even necessary, whether it would be -- whether it would be revoked and i know that's a real conversation that's happening so the future of those things are unclear. the proposed timeline that's included in the legislation would be difficult for us to meet, and i know that the supervisor's office who is going to speak after me has agreed that there may be flexibility with that timeline, but we did contact covered california after the board heard the item this past week and they told us that the earliest

they can assist us is in 2016 and they've been asked by the governor to do some similar programs for pregnant women and others and they have told him as well that they cannot implement anything sooner than 2016. there may be other solutions that would serve the intent of the proposed program. the program itself would be provide financial assistance to people who are purchasing insurance but there might be ways, so we want to have that flexibility in addressing this affordability issue. >> the current status, it was heard at the board of supervisors neighborhood commission last thursday, the committee agreed that additional discussions regarding the health

programming elements of the legislation was warranted and it was held in committee pending the call of the chair and they'll work with supervise campos commission. we're exploring southern california and organizations and other stakeholders. we plan to convene a meeting of covered california health plans in san francisco to see if there are other creative ways to address the issue of affordable and we're continuing on our analysis of access in trying to come up with feasible solutions, financial responsible for the city. >> healthy san francisco remains open to san francisco uninsured. until we develop a sustainable affordable program, we -- low

income, they'll continue to be eligible for healthy san francisco and will not be left without health care options for them. so that concludes my portion of the presentation and i'm happy to answer as you like. >> we believe that the intent of the legislation, we really do like and we really want to implement it, but we need the flexibility to be able to move as the system is moving. we didn't know that the covered california would say not until 2016 and that's just going to keep happening to us as we try to develop this. this is a new service line for us, and we've never developed subsidy and we'll need a third party, maybe one of our health plans to do that, so they'll be negotiations so what i want to present to supervisor

campos, thank you for the work being done, but allow us to do this work in trying to make the best program we can and then go back and try to legislate as needed if we do need that legislation because many of these issues we can do on our own. so we want to work closely with the supervisor to insure the legislation gives us the flexibility to be able to implement this important program and insure that -- and we as the co-chair of this council, it's clear to me that the affordable factor is an issue in people try to go get insurance. as an example, i for see having to keep healthy san francisco open past 20 -- this deadline we have, just to be insuring that particularly in covered california is not going to be able to help us until 2016, that's an automatic piece we have to look at and so we'll work closely with the supervisor's office to give us that flexibility in this legislation to insure those in san

francisco can get insurance. with unof -- one issue i was concerned, we need to focus it on the working individual so we have an off and on switch. once a department or government is involved in subsidy, that might be hard to stop, but on the employment side, we know that people know if you're working or not working you get certain benefit and i know supervisor was willing to look at that as well. so we would like your support to work the supervisor's office. we believe this is an important program. this is a system of a service that we just don't have right now even the staff to work on, but we're doing this because we believe it is important and we'll do our best to implement this and getting our flexibility to do our work as soon as we can on this. >> were there portions of the

presentations still that will be presented before we go onto public comment. >> mrs. brown from the supervisor's office and mrs. tran speaker: why don't we have those presentations too about we go into public comment. >> my name is hillary and i'm an aid for supervisor campos. it's good to see you. talking about our security health care ordinance and supervisor campos would love to be here, but the health commission is scheduled on the same day. hopefully we'll be able to pull him out of that meeting and speak before you. supervisor campos really appreciates the fact that the department of public health agrees with the intent behind the ordinances and understands thighs are complicated issues. we give discretion to the

department of health in designing the health care program. we can take into account the multiple concerns that there are and issues in determining subsidy issues and taking into account the fiscal concerns that we have as a city and as a department. we have been trying to work with the department for over a month to actually look at the ordinance before us and create line item amendments to the ordinance in order to get to a place that both accomplishes the both of the legislation which is to maximize the effectiveness of the way that the health change security ordinance works with the affordable haelts care to get san francisco insured. the department hasn't been willing to sit down with us and

really negotiate and make those amendments. however, i'm hardened to hear today and the supervisor did continue the item before the committee last weekend, in one more time to try to move forward. although we believe that our ordinance sets forth a workable vision of how to get as many san francisco workers and workers covered as well, we are open to taking away from of the language mandating a specific program. that's fine. what we want to make clear is to agree on a certain set of principals and accountability measures that accomplishes the intent and open to working on how we do that. in the meantime though, we

absolutely must act urgently to act with this ordinance which is the loophole in the ordinance that has allowed san francisco businesses to pocket last year over $90 million that should have gone to worker health care and as many of you know before i was before you many times in 2011, we tried to close that loophole then and we were unsuccessful and that loophole that's gotten worse overtime. i'm going to do a quick illustration. >> commissioners, it's before you. i gave you paper copies. it says at the top, supervisor campos." that's it.

>> great. i just wanted to briefly focus on the loophole aspect the ordinance which involves the health reimbursement accounts. as mr. tally explains when an employer meets the spend willing requirement by providing health care to their worker directly or using the city option, they don't get the money back when they use those two options. it's only through the use of health reimbursement accounts that businesses are able to claw back money that was intended for health care worker. health reimbursement accounts, as co-lien had mentioned, prior to january 2014, employers were allowed to use stand alone accounts and they can place limitations on those

accounts, but in 2012 which was the most recent published data on the use these accounts, 65 percent of the employers were allowing workers to use that money for premiums, deductible and co-pays. under the affordable care act, we know it has been outlawed. the only that's allowed under current law that's offered through health rebim ursment accounts is benefits like long term care and dental care. there's a list there and it's very, very upon to note that workers, the 65 percent of the work -- workers where they used to be able to public those accounts, by law they can't use the money for that purpose. we're in this really sort of

ironic situation that for the first time in this country's history, there's a mandate for individuals to purchase health inshoe znswer and we're allowing a mechanism to allow with the spending equipment that does not allow workers to access that money for the cost of health insurance. i wanted to give you a sense of the scope we're talking about. current san francisco law allows employers to reclaim money under hra after 24 months. in 2012 which was the most recent date, of the 107 plus million dollars that was allocated through these accounts accident employers reimburse 26 plus million of those dollars to workers. that represented 24.6 percent of