appreciate it. i know it's hard, but i hope we go there. thank you. >> thank you for your comments and your previous chairing of our committee also. >> hermanton and jim and amber and michael lion and those are the remaining public comments i have. if anybody else has public comments, turn in your form. >> commissioners, my name is berry. i am a green party activist and i also work very closely with the group called single or pay now. i'm an advocate for single payer health care. the aca is

an improvement, but it's a far cry from a truly universal health care system which we should enjoy. i'm a former small business owner. i owned and operated a business in san francisco from 1980 until 2005. and i'm outraged that we have a portion and i should say that i'm past president of my merchant association, one of the largest in the city. i'm outraged that a small portion of is taking advantage of the loophole and as in the hearing at city hall, there was a mention of cash flow management and i'm apolled to have a business and you pull 75 percent of everything you put into one of these accounts. that's not a sustainable business model. if only if are

the reason you're listing getting sued because someone like my age or who is handicap or whatever who you can spot immediately in an interview says i can't hire you because you need more health care and i can't afford that. we need a different business model to do this. recently there was an interview, dr. david was interviewed, he's a national activist for single payer, about the states who have not implemented medicaid. they have studied this and they're putting out this may result in 7,000 deaths every year as a result. we may have huge impacts because of this and finally i wanted to compliment on the previous agenda item in which you stated because there was some opposition to actually moving

forward on that initiative. you said we will learn as we do implementation. i would hope you would do the same with this. >> thank you, sir. >> jim, please. >> good afternoon, commissioners. jim accident san francisco chambers of commerce. it shouldn't surprise me, but once again we're bashing small business and the ability to su viefb under mandate after mandate. this isn't a loophole we want to change healthy california and come up with a new program for spending programs by the city and the employees to make sure every san franciscan can afford covered california insurance. that should be our goal. that wasn't the case in 2006 when

the legislation was drafted. we need to sit down with the mayor's office which we haven't done before the legislation before you today and look at how this works together, locally, state and federal. remember, we still have federal law that super seeds everything here as to the dictates that's allowed or not allowed by local government state or local over spending by employers on pensions and health care and that drives a lot of what's before you because for one thing if you have pat time employees, health care might not be available. you pay into the medical reimbursement account which doesn't get spent. that has a 50 percent draw down or using health care reimbursement accounts that has been changed

with the affordable health care. the legislation before you today is not the end all or be all to solve the problems we have as employers or the city or labor in complying with the affordable health care and make covered california insurance subsidi available for those in need to comply with federal law. thank you very much. >> thank you. >> next speaker is amber and then michael lion. >> thank you for having us here. i'm amber. i've had the opportunity to speak with many of these workers who actually have an hra and i take issue with the previous opinion that this is not a loophole. many of these workers are struggling

day-to-day, paycheck to paycheck and when they have an hra, they work under the assumption that the worker can pay and they'll get reimbursed through this and i work for the ahr and i'm married to a restaurant worker who has an hra. it's extremely challenging to draw down all of that money. i don't know if you have a credit card, but i'm guessing you do. most of these workers don't. you have to get online in most cases and try to figure out which cost are covered and which aren't. this are lots of restrictions on the money and what it can be used for. currently you can use them for vision and dental care. this is not a model that's set up to support workers and get them health care. this money is owed to the workers under a law and a fight that's been had

to pass the original acso. i'm lucky that i have health care, but many of these workers do not. it's high time we close this loophole. we've been here with you before. we respect and honor your commitment to getting the most people health care under this system and i appreciate your time. thank you. >> thank you. >> mr. lion. >> michael lion, gray panthers. i want to thank the previous speaker for talking about the complexity of trying to draw funds out of these accounts. i'm glad to see that the current resolution calls for continuing healthy san francisco in the city medical reimbursement accounts, but there's the question of covered san francisco. it's very frustrating for all us to

have to be dealing with health insurance plans which shouldn't even exists in the united states. and one of the glaring deficiencies in the aca is the fact that the subsidy offered to low income people take into account in no way in the differences of living cost but the differences in insurance cost and premiums them self. san francisco is not only a high and expensive area to live in because of housing and food, but also because of health care premiums. and so it is really necessary for san francisco to be able to

immediately subsidized ongoing to californiament if you delay on this, many people will go without insurance. and they'll get fined but there could be disaster health effects. >> thank you. further public comment. >> i haven't received public comment. >> we have questions to our presenters. >> did you want to start or any other commission that wish to start. i wish to frame our discussion because i see this as a further study of our own resolution of february which asks that the department work with and will then present to us solutions in regards to the issues that we raised in the question of affordability and access and

you recall that within that period of time we said we would maintain healthy san francisco through 2014 while studying this whole issue. this ordinance certainly falls within that whole scope, and i think you've heard from staff already some of the issues that have been placed on the table and for which the department has been working with the supervisor and with the mayor's office to try to respond to a very complex issue. disclosed and i know the question of 2016 and 2017 has come up and the 2016 as i understand it is actually what covered california has told us, so i'd like to get an explanation of that because that has come as a question, what is the date that we're aiming at along with the

various complexity. our intend is to bring people in covered california. >> according to the recent conversation, i'm trying to set up a meeting with peter lee to see if there's more flexibility with that. according to their office and they'll been asked to do work with the governor and they've been given the same response that they don't have the capacity until 2016 but in meantime what we're attempting to do and one of their suggestions was work with our local health plan because they don't want one off -- they look to the other counties if there is this type of model that they're interested in so we can work together with both of health plans and also i'm looking to work with the local foundations to see how we could develop this

program as soon as we can in considering the covered california has to be receptive. that's one path which is the covered california and what their needs are, but in the meantime we knew this was going to take us time to get done. we have to work with the local health plan to see how we could potentially set a program up with them and foundation world to see how they can participate because that was one of the thoughts we had preliminary is could a foundation help us provide these subsidies. we need to be mindful that i'm looking to recommend that we provide the subsidy for the workers. it's

hard to take away an subsidy and we figured out an amount of subsidy to go to every person and what happens if that dollar isn't the same dollar. there may be changes in how many money is collected. because there's this off and on switch for workers, are you working there or not, i feel there's a little bit more safeguard there that we can be working on behalf of the workers to insure that they get these subsidy. we were working with the deputy and peter lee so they understand our need to move forward on this, but we do have some work to do with the health plans and trying to structure this. >> okay. commissioners? >> sir, i wanted to clarify the intent of the ordinance because i think there's some confusion. i can understand if covered

california isn't ready to create a direct easy system for the city to provide the subsidy to purchase the care, but that doesn't mean that we have to wait until 2016 to act. >> our legislation -- >> i'm not saying that. first of all, what i'm saying and this is apart of our process is we're going to start working with the groups to see -- covered california is going to have to be a participant agency eventually so we're going to work with them on this, but we can work with the health plans to figure out how to do this and that's why we're working with health plans along with the foundation. i'm not saying that we're not going to implement until 2016. covered california cannot accept our process until 2016 but we can work with the health plans and that's why we're going to work with them to see the potential of us doing that. >> i would actually ask that we address the chair so we can keep some decor, that way we can hear the

full comments of each the common tate tors. >> i want to clarify, what the legislation directs dhp to do and we're open to change the language so it's more intent, but i want to make sure we're clear about what we're talking about. it mandated dph to use the money coming in through the employer spending requirement to provide an additional subsidy to workers who are paying on their behalf to be able to afford health insurance. how that is mechanically given to

the worker whether it's given directly to covered california or a reimbursement coast -- cost paid for by the worker, we're leaving it up to the health commissioner to come up with those designs. especially given the comments of amber and what we have heard from workers, because they're so low wage, it's hard for them to make payments so they can give that money directly to covered california. but, you know, moving forward on this legislation, and if we have to start with some reimbursement program before covered california is able to work with us to create that direct subsidi program is better than the status quo. >> thank you. did you have any

further comments director -- >> the fact of what i was saying was southern california was not ready for us to work in this way. this would go to them from us and we'll be working with health plans to see if there were other ways to do that. >> there's different mechanisms you're describing and we're going to have a direct talk. >> we understand there's been some foundations who have been trying to do this same model so that's why we want to work with the local foundation. >> i appreciate that comment. comments from commissioners? commissioner mcgee. >> thank you very much, chair. this question, i guess is directed to director garcia. i want to make sure i'm clear about what the -- what the timeline is? my understanding is that the problem from the department of public health perspective is affordability and the timeline, am i correct? in

principal, are we saying that we support closing the loophole, but we want more time to do it? i need to be clear about that. >> there's two distinct pieces. the loophole is one distinct process that will contribute to the other or if the loophole did not get passed, we could do this through what exist today. we don't need personally -- what i was concerned about is we don't need this legislation to do work we need to do. what i'd like to do is to form a problematic process and see if there's legislation to do this. at least not on the loophole side but on our role of processing the service. we would need to be able to develop a financial model for health plans to receive these scholars for individuals so we'd have to work with the health plans to come up with the model of how we do that. we also have determine how much money we would be giving for each of these individuals and be able to work with the health

plans to figure out how we do that. so there's also covered california as a way to provide these dollared to covered california and they're not ready to do that so that's why we're working with the health plan. we have to see how much we're going to subsidized them for and we have to develop a financial structure of a fee schedule and how we're going to do that, who gets the subsidi, do they want the subsidy, so we have to have a process. we have to work on all those elements. >> a followup question on dr. garcia. what's the timeline that you envision, that you would need to do what you said? >> i always know that these kinds of processes that i've had experience for in the department can't happen within a year. they use today happen within 12 to

18 months. i'm saying that without knowing what i don't know. it's important to sit with the health plans to see if it can happen quicker and there's the ability to set a standard of a fee schedule of how much people would get for the sub is it sidies and that will take time along the structure. from the top of my head those are what we'll be looking at. speaker: i have one more question. >> director garcia, the idea of the foundation and a foundation being able to fund and they're looking at restricted funding, but what you would be thinking of from a foundation that's large enough and how much money are we talk beginning? >> we know how much money that could be there. it's not like

we're asking the foundation for funding. we would be moving the dollars through the foundation to provide these subsidy and we could see the dollars with the fact that the supervisor's office was willing to keep it to the working individual, that makes it easier for us to not see the potential of the financial piece because you're working with that employer or finance and that subsidi would continue until you exhaust that. these are the things we would have to work on so that's why i think it's important to sit with the health department who do these work and have the subsidy for these individuals to get insurance. they're a key part. >> commissioner sanchez. >> i've been listening -- i'm

sorry, colleagues. >> i can understand the consent. this is complicated and be have san franciscans whether it would be old timers or grand kids of people who work in industries like the restaurant industry and other others where they get, you know, minimum wage and are dish washers and are undocumented. they have trust in san francisco and the fact that we have problems here and not all of our people have continue access or quality. we had hearings on the safety net at san francisco general. elevators being fixed because we didn't have money in the budget. quality care and nursing ratio. whatever. we have a whole lot

of challenges in this city and that's the frustrating part. but as i listen to the community speak about this, part of the problem has been covered california. they can't get through them or they paid their money but they never received a card from the insurance company so when they try to make an appointment, they don't have an id card or the fact they had to take the bronze level because that was the least affordable and they couldn't do whatever. all these things are valid and we're talking about the same issues. how do we provide the highest quality program for our people when at the same time, this public health department is only about 65 percent of where we should be where we were ten years ago, 15 years ago, 20 years ago. we are not operating at our maximum pertaining the fiscal need of what this county of san francisco needs

and that's apart of the frustration, okay. many of our people who were key staff people over the years, they're no longer with us because there were decisions made. we would protect patient care and eliminate a number of the support services for these support efforts to write extra grants, to do data collection, you name it. we cover the water front, okay. we still haven't built that up yet, but we're trying to maintain the quality of patient care and at the same time work collectively with our people across the street who believe in our concept. can we still implement a program because we have more faith where the rubber hits the road in the city than the

state or the feds because it can be done but the old saying, when the going gets tough, the tough gets going. when you shuttle all your troops over the years and try to bring them back in, it's going to take a while to address this issue. so conceptionally i fully support this area. at the same time i do have mixed feelings because i know that our partners covered california are not yet up to the task. we are partially because we're doing multiple things and this department has always taken pride -- if we're going to focus on this, we pull people from here and here, a lot of people aren't here anymore. we all know that. so the question is, how do we navigate this so we insure that this key area, you know, is still

ongoing and will come to fruition pertaining to providing a unique with san francisco and what we have always tried to do and hopelely fully we can continue that going. >> can i respond commissioner chou because there were a lot of questions that i have responses to that might be helpful to the discussion. >> okay. >> you brought up a number of important points and i would respond to five of them because you said a lot about this statement. the first was about this being complicated and you know anything health care relate in this country is complicated but i don't want to over state that fact. i want to simplify what we're talking about because i don't think the vision is that complicated at all. we're talking about two things. closing a

loophole in an ordinance that has allowed employers to steal $90 million that was supposed to go towards health care. how do we get that money? it's reimbursement. we're adding a third component is called -- we want to steer workers to purchase health insurance. they can use that for any means and you can use it as a newport and this was exciting to me, to purchasing diapers and that's really expensive and important. we want to get san franciscans insurance to covered san francisco, instead of giving the worker the option to use the money, we're saying we're going to require you to get insured because when

you don't get insured it falls on the tax payer when you end up in general hospital. we're trying to use that $90 million that's being pocketed by businesses to use that money more efficiently to get insured. i think everyone in this room can understand that concept. number two -- >> i'm sorry. let me back up for a moment because you thought you were going to answer five questions but we are in a dialogue between the commissions and recognizing and honoring you as a representative of supervisor. i was hoping would be short answers to perhaps some of the factual issues so i think -- >> i'll try to be short but it is a critical conversation and i would hope you allow the time. if this is so complicated we should have the time to talk about it.

>> i'm sorry to permit you to speak about the five points but within a sustained period of time. >> the fiscal impact, we're expecting if this passes, a lot of workers using healthy san francisco would instead get insurance. so we would expect they'll be a positive fiscal impact on the department. number three, covered california, there are a ton of difficulties. if anything, this legislation will make it easier for workers to be able to afford the really expensive insurance through covered california. number four, we have talked to the blue shield who wants to work with the department to help fund the program design of our legislation and number five, in terms of time line, we're more than happy to work with the department to establish the timeline that

would work for the department. >> thank you very much. i really appreciate this because that gives us that perspective and opportunities that you're describing which we hope the department will take advantage of. commissioner singer. >> i had a few questions. co-lien, it's great to have you here because you make complicated stuff retractable for me. i don't know if you have the sense, but when you think about each of the buckets that everyone flows to and proposed legislation, how many people are in those? speaker: it's two ways to think about that. thinking backwards with the remaining uninsured, we think they'll be between 43 to 52,000 who