specifics as to the extent to which healthright360 intends to meet the plans of the goal we so interested that into the resolution and it's more spivelg how healthright360 will meet the goals of the plan and i know the executive director is here of healthright360 if you have any questions for her. also in response to the health commission's conversation we discussed how healthright360 would come back a year after opening to talk about how they're meeting the goals of the plan so we've had some preliminary conversations about what such a report to the health commission would look like at that time. >> thank you. commissioners you have the draft resolution redrafted from our input before you. was there any public comment? >> i have not received any public comment requests. >> okay. commissioners so we're prepared to have a motion for acceptance of the resolution

before you. >> so moved. >> and so i heard a move and a second move which say second so we're ready for discussion. discussion of the resolution? commissioners, yes commissioner. >> just for clarity this is the first time we have done this based on the new process, correct? so i am pleased we have the built in follow up that we're going to see this because this is sort of our testing how this process works so i am pleased we have it in there. >> thank you. >> thank you. commissioner singer. >> yeah, i second that thought and colleen i have a question and thank you very much for the follow up. it was thorough and helpful. i don't have any questions regarding this particular motion but i was curious about what appeared in here to be kind of a pausity of data relating to the actual patients searched in the past and more related to what is the zip code -- the demographics of the zip code and i hope it

adds. our it system gets better as we have new programs and approve and constantly thinking how do we improve our data collection because i think that will lead to a more precise understanding who we're serving and who we need to serve and aren't. >> certainly we will make note of that in future applications. thank you. >> further comments? if not we're prepared for the vote. all in favor say aye. all those opposed? the resolution is passed. >> congratulations commissioners. the next item on the agenda is a proposed changes to eligibility requirements for healthy san francisco and the administration of the city option. >> so here i am again. i am not diana. i am presenting the changes -- the proposed changes to healthy san francisco for you

particularly they came out of so many policy endeavors we under took last year and early this year. so the genesis of the proposal that you have before you is really -- has many elements. first we wanted to align healthy san francisco with the affordable care act. we don't want to create an disincentive to take up subsidies on covered california but healthy san francisco is available to those that can't avail themselves to those options. secondly as you're aware the hospital department convened a council in late summer and fall and made recommendations that were related to healthy san francisco. among them were the expansion of healthy san francisco to certain populations specifically seniors and people not subject to the mandate scprts insuring that healthy san francisco remains available to

them and that's what these suggestions do today. also minimizing gaps in health care coverage for san francisco residents. as you know any applicant to healthy san francisco comes in and the eligibility workers help them find whatever coverage they're eligible for and make the best financial decisions for them about own roling in health care coverage. the recommendations increase the flexibility of the city option to facilitate the option of health insurance coverage and as the health commission remembers this has two components. healthy san francisco is one but for those not eligible for healthy san francisco it's medical reimbursement accounts and reimburse people for the health care related expenditures. the recommendations also continue the healthy san francisco mission of serving populations not available for aca --

eligible eligible for aca and important state and federal dollars are maximizing before a local dollar is used to support health insurance. so just an overview. there are two components to the changes we're proposing today. one are changes to healthy san francisco eligibility and the second are changes to the city option. so changes to healthy san francisco eligibility there are three key changes we're proposing today. the first is to remove the upper age limit so currently healthy san francisco is available for 18-64, but this leaves out seniors who are otherwise eligible for healthy san francisco, seniors who are undocumented or seniors who have not qualified for medicare are not eligible for healthy san francisco and this was one element that was raised in the universal health care council with san francisco aging population as something that is important. our current estimates indicate this would be

about 1200 san franciscan if we remove this limit and be eligible. the next is decrease the limit to 400% of the federal poverty level and align the income limits to the income limits for subsidies on covered california. currently anyone with income 400% of poverty or less is eligible for subsidies on covered california so this would mirror that. currently there are fewer than 175 healthy participants that have income in that level and of the 25,000 currently enrolled in healthy san francisco so those individuals could retain their coverage until their next renewal time. at that time they're no longer eligible for renewal and then the third change that we're proposing for you today is to extend the healthy san francisco transition period for covered california eligible employees through

december 1, 2015. the health commission previously approved the extension through 2014 and said in committee today to allow what is newly health insurance availability to many people. not everybody knows how to navigate it so to make sure everyone had care during this period. we are proposing extension through 2015 for the department to come up with the affordability program that was discussed earlier so the health care security ordinance amendments passed by supervisor campos this year required the health department to come up with a plan to make health insurance on covered california more affordable for individuals that have employer contributions so we're working hard on that plan. we will come to you by august of 2015 but while we work on that affordability program we wanted to extend healthy san francisco to make sure no one is

without health care services because of affordability issues so these are the proposed changes for healthy san francisco eligibility and if it's approved by which commission at your october 7 meeting then they would be effective january 1, 2015. the second group of changes is to the city option which again is a medical reimbursement account or healthy san francisco. previous to health reform if an employer corrected to the city option on behalf of an employee the city option if they're eligible for healthy san francisco so if they're a san francisco resident and not otherwise insured they are automatically put in healthy san francisco and made sense before health reform but now it doesn't make as much sense because if i have an employer contribution made on my behalf and it's may and i can't enroll

on covered california until november because that is what open enrollment is so then it gives the contribution to the city for healthy san francisco and i cant use it to pay for the insurance once i am eligible for it so this change would help with that. it says rather than giving an employer healthy san francisco if uninsured will give them a medical reimbursement account so that way they can accumulate contributions once they can buy health insurance. the second element of city option or the recommended change is waive the documentation requirements to transfer employer contribution from healthy san francisco to medical reimbursement accounts and right now we ask for this and removes this barrier so if these are removed from the health commission they

would go into effect more quickly to enable people to purchase health insurance on the exchange and implemented november 1, 2014 and that is the conclusion of my presentation. you have in front you a resolution that would implement these changes and for your consideration and vote on the october 7 meeting. >> thank you. commissioners we have one public comment which i think we will take at this point. dina long. >> good afternoon commissioners. i am the vice president of policy and advocacy at the san francisco community clinic corsortium, coalition of nonprofit clinics. we work with dph on many things including healthy san francisco program. i am here to support changes. the post 65 while it doesn't affect a huge amount of people is important to the clinics because they couldn't explain

to a senior who was comfortable lean at a clinic for years once they turned 65 and not eligible for medicare and get this program and helps the seniors. the other thing i wanted to mention i think there is uncertainty in the community because we know that healthy san francisco is shrinking and it's because of a positive reason. they're moving primarily to medi-cal and get comprehensive insurance and see the same provider in most cases but i think we always need to be clear to the community what we're doing and why and this program will remain for those that still need t the other thing i want to mention i go to meetings with other clinic consortia and in many reports say that the clicks have a hard time. >> >> clinics scheduling because they haven't had service for

years and coming with chronic illnesses and we aren't experiencing that as much in san francisco because we have healthy san francisco so someone moving to medi-cal from healthy san francisco doesn't have as much back up care so let you know we improve health with this program we hope to continue. thank you. >> thank you. >> commissioners, we're prepared for questions. i would like to start with the first one because i am curious about this slide which is up right now. all employer contributions, so that means that the people who are paying into healthy san francisco in the past we sent the money either to us or those who lived in the city or eligible and we sent it to a reimbursement account if they lived in san matateo or outside

the city but now you're saying it would be sent into -- an account that the employer has that it goes into? >> let me preface by saying that the health security ordinance mandates the contributions and the vast majority of funds provide insurance for people so 88% of the funds go to provide insurance. some go to provide healthy san francisco or the city option or other accounts, so this is a smaller proportion of all of the employer contributions ever made in the city, but what happens now if it goes to the city option the city does one of two things with it. if the person is a san francisco resident and doesn't have health insurance regardless of their income then it automatically goes into healthy san francisco so the person is given an opportunity to enroll in healthy san francisco at a discounted rate. what we're seeing now is the funding would automatically go instead into the medical

reimbursement account and that individual it use that to purchase insurance on the exchange and accumulate until they are eligible to purchase health insurance. >> so if choose to sign up with healthy san francisco is that still the option? >> we can convert it at that time. we wouldn't go back and take retroactively retroactive payments but we could convert it and with healthy san francisco. >> so you're saying through -- this is actually through the 2015 and your recommendation even if they were eligible for the exchange they still could come into healthy san francisco if we passed the extension through 2015? >> that's correct. >> so then they hold an option either to use that money from

the employer to partially or fully be able to purchase on the exchan they could continue to in healthy san francisco. >> that's correct. >> so it's one mechanism for everyone coming in whether they're in san matateo or not. it all goes into a medical savings account. >> medical reimbursement account, yes. >> sorry. >> those funds are administered by the san francisco health plan and not reimbursable to the employer so they're with the employee for the life of the account. >> they with the employee for the life of the act so they can spend it years from now. >> that's right. >> okay. all right. commissioners any further questions? i thought that one --

>> i have one question, one comment, so it sounded like this was 12% of the dollars but i'm not sure. >> less than that. >> and how many people is it? >> do you know how many people have that employer contribution? >> it's actually a very small number. i am sorry to say i don't have the exact number but i know it's less than a thousand people. it's about 500 i think. the one thing i wanted to comment on is if you're a san franciscan and are within the 400% or earlier -- within the 500% regardless you are eligible for healthy san francisco, and it really the impact on the city option are those that are above where we don't set the limits and therefore there's a contribution requirement for them, so the impact will be

minimal even for this group who will have a district contribution to the mra because they will be eligible according to the benefit rules of healthy san francisco, so the option is dual for them. >> if i can also clarify, so there are really kind of two eligibility rules for healthy san francisco. if you have an employer contribution then regardless of your income you can be eligible for healthy san francisco if your employer is contributing to it on your behalf you're eligible for a reduced amount. if you're applying and don't have the employer contribution then that is the maximum. the other thing i will say diana said there are fewer than a thousand people but only about 25% of employee who is have employer contributions to the city option actually enroll in healthy san francisco so it's a small proportion of

the employees who have city option contributions. >> so -- thank you very much, and then my comment was as follows, so this is totally impressive work that we do in san francisco that most municipalities don't do and try to find the cracks in the system where people are falling through and make sure that they get care, and we heard from the one -- the public comment just prior to this that that actually pays benefit because you end up with patients -- many come. -- many come back into the system and they're in better shape than others and i should take a moment to congratulate ourselves on that, but -- and here's the butt, i don't know

about anybody else but if we're going to have a resolution that suggests changes to healthy san francisco we have a responsibility to all the people who are falling through the cracks to get these things fixed i think we have another responsibility which is to just make sure that financially we understand the decisions we're making, so to have a resolution like this, and we have a couple more today i think -- without some sort of sense of "here's what it's going to cost" not because we make every decision based on dollars and cents but because it's good public hygiene. i don't know how the rest of the commissioners feel but i feel it's got to be more engrained how we do that because we owe it to the public. >> we will bring that back with the financials. i think that's

a very good point. >> commissioner. >> which of course is a transition -- leeway from that question is what will the affordability program look like? >> that's a million dollar question. we have drafted a scope of work. we looking for a consultant to sort out two things and one is the numbers around it so how many people are we talking about? how much would the employer contributions be? so it gives a sense of the size of the program we have to work with. what is affordability? how is it different here than other places and that calculation? so that's the number side of things and the second deliverable we're looking for in a consultant what are the mechanics of a program? do we give a subsidy after they have insurance? do we work with them to make it cheaper to the individual at the out set? do we work on out of pocket costs

and where we can have an impact on that. we have spoken with consultants in the area and foundations interested in funding us and not just us but this has implications how other jurisdictions might want to make health insurance affordable too so we approached it with an eye of capcablity too so we're looking hard at that question. >> excuse me. just as a follow up what is the cost? you said you have foundations funding you. what are the numbers on that? >> i don't have numbers for you yet. we had one proposal come in at $90,000 to do that analysis, but that's one of many that we have talked to so that's the only numbers i have right now. >> thank you. >> thank you. >> commissioner.

>> just to have a couple of minutes to crunch the calculator here so 400% of the current federal poverty level would be approximately $46,700 and 500% is feat thousand $350 so when we change that. >> >> >> what kind of transition do you anticipate? >> sure. there are fewer than 175 people between 400 and 500% of poverty currently enrolled in healthy san francisco of the total enrollment so the mechanics would be upon their reenrollment date then they would be determined not eligible if their income was still between 400 and 500% of poverty so if a person enrolled on december 30 of this year they have until december 30 next year to remain on healthy san francisco. >> okay. so i think that

where i am stuck a little bit is i mentioned earlier affordability is kind of relative and for a city like san francisco like the cost of living, like how much can people actually contribute to any of the tiers and i think that's also why we are seeing people opted for the lowest tier often of the different exchange programs because they can't put more into it, and so the question that i have here is that this doesn't really translate to the reimbursement account able to cover that differences. >> yeah, those -- yes, those are two different things so the income eligibility limit is for people who don't have an employer contribution. if a person has an employer contribution and they're

otherwise eligible then they can participate in healthy san francisco at a reduced rate. if the person doesn't have an employer contribution then the income limit is 400% of poverty, and the difference is true today because now the income limit is 500% and if a person with employer contribution has increase of 600% they can still participate in healthy san francisco so it's the same it's just lower in alignment with health reform. >> and people need help figuring this out during this period of time. are there navigators that can actually -- >> absolutely, absolutely. >> just listening to it i got dizzy and we need a color chart. >> this program has become more complex i think. commissioner sanchez. >> no. i really enjoyed the presentation want i think you hit the key areas that may have been areas that didn't have

access and/or -- i was interested particularly where the age limit of 62 is being eliminated because i really believe that we have a significant cohort of people who on minimum income or are victims of elder abuse whether financial, physical, economic, you name it, and these are key issues now being discussed in a number of committee it is state wide and within counties. >> >> and it's a real, real problem and we know we have numbers in urban areas of san francisco and l.a. that we have people who don't have access because of specific requirements so i think this opens up another pathway where we have a chance to really provide services pertaining to the cost -- if

there isn't any, and i think all are important for us to have as a commission, but i think the fact that you and others have factored out these areas are really important pertaining to are we really providing maximum government access and quality care to those who could be part of our programs as an option? so i would certainly support the resolution when it comes up for a vote. >> thank you. >> commissioner. >> just thank you for listening the public feedback as well as the conversations we've had here to deal with the transition of healthy san francisco and the affordable care act. i think this reflects that kind of thoughtful approach and i do think that begin this next year because a year from now then we're going to have the same problem. what about everybody? because they're all going to be off healthy san francisco if it goes this way and gives

breathing room and key to look at the costs. if we went ahead without passing this what would happen at the end of this year and both costs to not provide the services which is the other side of it the costs. i think this is reasonable and it looks like a reasonable way forward with a lot of input so thank you. >> thank you. >>i upon to thank the commissioners for. >> >> i want to thank the commissioners for considering this. we didn't have the pent up demand that many communities had. we wanted to strike continuity of care and we have a mandate and issues that has a city that is more expensive than others in the country to survive in and then to pay for increased health insurance, but access to health insurance which they never had before and we have the health care security ordinance -- particularly the employees contributions. that really helps with that so there are

millions dollars there that we can craft to help people support their insurance. it's a very -- we had a whole 40 member team that crafted this next phase of it and some is something they wanted to do is look at affordability over all in san francisco so we will come back with the financial review of that as well. >> so i have still one question that was raised in regards to the seniors which i think we need to flesh out a little more because currently they're not eligible. then we're saying that people who are over the age of 65 will become eligible, but then what rules are we going to use to make sure that they are going to accept the insurance programs they already can access, the medi-cal -- medicare even? medicare has --

continues to have a big donut hole for example so we're using the analogy of under 65 and feeling that some of that's unaffordable what are we going to use for some of the measurements to avoid a number of other seniors who says "gee, this sounds like a better deal and close my donut hole and i've got a 20% program that really costs me x dollars as a part b and therefore what is it that keeps that we continue to encourage that those who have insurance don't? because this is a brand-new group. they're not already in healthy san francisco. i see a rule that says if you're in healthy san francisco and eligible we understand because we understand the parameters right now and below 400 or 500 and not having any other insurance except the affordable care act which we know has a

number of things that make it unaffordable right now. that isn't necessarily true for seniors so i think we need more definition how we're going to be assured that a normal seniors today with their wrap around programs, and the part b big donut hole remaining not see this as an opportunity to reduce their costs. >> no. in fact seniors eligible under the expansion are otherwise eligible -- meet all of the other eligibility requirements so not eligible for the pubally subsidized health insurance and you need to be unemployed for that for healthy san francisco and that will be the case and anyone eligible for medicare will have medicare and not healthy san francisco. >> okay. i will assume that