>> the meeting will come to order. this is the regular meeting of the budget and finance committee. i am supervisor fewer. i'm joined by supervisor stefani and supervisor sheehy. can we have a motion to execution supervisors cohen and yee? thank you very much. i think we can take that without objection. our clerk is linda wong. i would like to thank jim smith and jesse larson for broadcasting this meeting with sfgov tv. silence all electronic

devices. speaker cards should be submitted to the clerk. >> madam clerk, can you call item number one. 180250 update on the board of supervisor's budget priorities for fy2018-2019 hearing on identifying the board of supervisor's surveyed budget priorities for fy2018-2019, and reviewing the budget committee priority hearing schedule; and requesting the budget and legislative analyst to report. 180223 human services agency and department of public health - >> thank you. we have a present from the budget and analysis office. >> supervisor fewer and members of the committee. i'm here to provide a brief update on the board's budget priorities process. as you may remember, in february, we solicited the top three citywide budget priorities from each board office. the three most frequently cited priorities during that process were homelessness and housing, clean streets, and public

safety. in addition, several other priorities were cited but much less frequently than the previous three. you can see them listed on the slide here. we have been in touch with several board offices to clarify their intent where cases there was any ambiguity and understanding. as we move forward, the budget and legislative analysis office, this analysis will include the status of established programs related to these areas, historic spending, any identified performance measures, and other quantitative measures of progress and identification of funding impact opportunities that the board can take. for the less frequently cited priority areas that were listed on the previous slide, we'll be providing a more high-level

analysis. again, we will be providing policies to specific reports and presentations to the committee based on the schedule on this slide. so the first would be april 12th, we would be reporting on clean streets. april 19th, on public safety, and april 26th on homelessness and public housing. and may 23rd, discussing all other priorities and next steps. we'll provide written reports to the board prior to the date. and this is a reminder the goals of the process, as we understand them is to synthesize a list of priorities for the board to provide to the mayor to guide for the proposed '18 and '19 budget. also to provide more analysis to the board and understand

opportunities in critical areas. the budget priority policy is new this year. we encourage feedback in order to make improvement for the current budget cycles. thank you. i'm available to answer questions, if you have any. >> colleagues, any questions? >> supervisor stefani. >> are these measures with how to deal with the homeless problem or a dent or the public safety or police officers, things like that? >> it's a combination of performance measures tracked by the controller's office, the city service's auditor, as well as other performance measures we can easily identify. we're happy to receive any suggestions by board offices for those. >> thank you very much. let's open this up to public

comment. are there any members of the public who wish to speak on this item? seeing none, public comment is now closed. would someone like to take a motion to file this item? >> i move we file this hearing. >> seconded by supervisor sheehy. we can take that without objection. thank you very much. now we are going to pause are budget and finance regular -- no, not yet. sorry. can't start that until 1:15. right? okay. let's, then -- >> would you like to take a mov finance and select committee. i'm joined by supervisor tang for this committee. can we excuse supervisor cohen from this meeting please? >> so moved.

>> we'll take that item without objection. can you please call item one for federal select. [ agenda item read ] >> thank you very much. is city economist, mr. eagan, here to present this item? >> we are still waiting for him. we can present the other slides and hope he joins us and gets to his slides at the end. >> that would be great. so please identify yourself. >> i'm from the controller's office. >> so, may i have the overhead? thank you.

today we'll have a combined presentation from our office as well as the department of public health and the human services agency. the federal budget and federal tax reform impact and then policy changes in public health and human services agency, and we'll also speak about related state funding issues. we're kind of rolling some of those state issues, as well, into is this topic. so you're probably reading right now that the house just passed a spending bill for the current federal fiscal year, which ends on september 30th. in february, they approved sort of a larger two-year budget package with listed spending caps overall. and there's various provisions in that february legislation which allocate funding for different programs, which will go to states at varying levels,

notably for fire relief in california. also, to extend authorization for children's health insurance program funding, which dph folks will talk about in a moment. tomorrow at midnight is the deadline to pass the budget for the current federal fiscal year. should it not pass, we would have another federal government shutdown potentially. so the goal is to avoid that. but what they are doing right now is allocating spending for a variety of programs. some key sticking points are border wall, immigration, and a number of other topics. it's gotten through the house. now it's going through the senate. >> next we're going to talk about the impact of the budget

passed in december of 2017. >> thank you, michelle. good afternoon, supervisors. i'm from the controller's always. our goal in presenting these two slides to you is to give you an update on where we're at and understanding the larger macroeconomic effects on the tax cut on san francisco. what we'll be sharing today is research that's done by the joint committee on taxation and congress on the national economic impact to sort of set the stage. then we'll begin to talk about what we know about how this will effect the city. overall, there are three main traunches of changes to the federal income tax associated with the bill that passed last december. on a net basis, over ten years, it will increase the deficit by about $1.5 trillion. it's shown on this graph. it breaks down to a $1.1 billion decline in revenues from individual taxation, about a

$650 billion decline in taxation from businesses. offset slightly by $350 billion increase from international activities that will be brought back to the country. breaking down some of the specific policy changes on the individual and business taxes that make up the totals that i just shared with you, there are many, many different things that change in the tax law, but the two most significant are the lowering of the tax rates. so for individual taxpayer, that's families and single individuals. the tax brackets widen in a way that generally at every income level, the overall marginal income tax rate is lower. the brackets change and the rates go down, with a couple of exceptions. that cost the federal government about $1.2 billion. a significant amount is clawed back by the repeal of the personal exception, which is a

$4,000 per deduction exemption that households get. there's also a change to the standard deduction, which is increased under this proposal that has the affect of costing $720 billion over the ten-year period that jct is forecasting. that essentially is going to encourage people to take the standard deduction. something that's very important for san francisco is going to be in for california particular. it's going to be partial repeal of the deduction for taxes paid. so currently, state and local income taxes and property taxes are subject to a deduction from taxes that will now be capped at $10,000 per household. and so that will probably result in less deductibility from any san francisco households and fire federal taxes for that reason. i'm welcome to take questions on this to the extent i understand the details.

there's an exemption for folks who are generally above middle class and up who are subject to alternative minimum tax, the exemption for the tax increase that reduces their amt payments. the child tax credit generally increases, although, it's also true that the income limit you're eligible at increases as well. more households will be able to deduct more per child. there's also a tax change that kind of splits individual and businesses. they've instituted a 20% deduction on income from pass-through entities, which is an s-corporation, a sole proprietorship, a partnership. within income limits, i believe it's up to $350,000 for a joint filing. 20% of that income comes from that business is deductible.

on the business side, again, by far the biggest source of the overall loss in revenue associated with the business tax cut is lowering the corporate tax rate to 21%. the other things that claw back some of that is limitations on the amount of expenses businesses can deduct to 30% of their taxable income, a change in the way the net operating loss works, changes into the way some businesses amortize their expenses. what does it do over the years? most of the changes focus on the economic impacts and impacts on income distribution. the jct has calculated the impact on distributions in several years from 2018 to 2027. in the early years, every income

group is paying less in federal taxes, but by the end of their forecast period, at the point of which many of the changes become permanent, you begin to see this pattern that's show on this graph, which is basically an increase in federal income tax payments for households that make less than $75,000 a year, all of them, and a decrease in federal income tax paid by households that make over $75,000 a year. you can see on the far right column the percent change in tax payments that applies to that household. so the wealthiest households get a 1% reduction in their income tax payment after 2027 whereas households in the 20 to 30,000 income range have a 26.6% increase in their tax payment. in terms of their overall economic impact, there's discussion about how that comes about, but the jct, which is a bipartisan research group in

congress, estimates there will be a .8 percent increase. during the period, depending on how you account for what revenue neutrality is, to the point that has to be paid back, that will create an economic anti-stimulus, but in the early years, we should expect an economic stimulus. the jct has estimated that stimulus is fairly large. the growth associated with the tax would reduce the net deficit to about 1 trillion. if that turns out to be true, that would be an extremely stimulating tax cut, much more so than we've seen with other tax cuts. at this point, we don't have some of the advantages that the researchers in washington do in terms of the access of the irs tax filings, so it's difficult

for us to crunch the numbers in exactly the same way. we're beginning to look at how we can do this without having too much error, but we would like to be able to answer among others, questions like, what is the overall effect on san francisco households? >> on one hand, it means some people will be paying more. i didn't mention the decrease to the deductibility of mortgage interest. that's another thing. it used to be possible to deduct up to $1 million. that's been reduced to 750,000. some san franciscoens with large mortgages will pay more as a result. on the other hand, we have a lot of households getting rate cuts at the upper end. we would like to get to a point to where we could say san francisco households overall pay more or less. it's much more clear that the

san franciscoens will pay less. we're going to try to estimate, within a reasonable margin of error, how much less. we'll also try to adjust the impact or estimate the impact on the distribution in san francisco. will it be similar to what the jct has estimated as a country as a whole? could it be worse? we'll see if we can estimate the overall economic impact. for example, if it's a tax reduction for the business community versus households. how does that work out? we'll take on any research tasks that you would be interested in hearing about in a later hearing. >> any questions, colleagues, for mr. eagan? >> none? let's open this up to public comment. are there any members of the public that wish to speak on this item. seeing none, public comment is now closed. >> we actually have more slides.

>> more slides. i'm sorry. yes. please continue. >> thank you. i will just briefly present a state-issued sb1. it's an act passed by the california legislature last year which generates funds for transportation and transit in this state. imposed a $0.12 increase for gasoline and various other fees. the annual value of this to san francisco is approximately $60 million. about $23 million comes to the department of public works for various paving activities, which would be a general fund to the extent the board chooses it, and $38 million per year to the mta for both operations and capital. there will likely be a measure that qualifies for the november

ballot to repeal sb-1, eliminate the tax increases it contained, and to then mandate voter approval for any future gas tax increases. it would be effective immedia immediately, which for the purposes of our upcoming budget balancing, $15 million of lost revenue for street paving and $25.5 for mta activities in the next year. that's a big contingency we're looking at. next, i will turn it over to greg wagner, the department of public health. >> supervisors, greg wagner. department of public health. briefly on the state of public issues affecting the public health. michelle mentioned the

february 2nd-year budget deal. there are two pieces of good news in there. one is extended funding for the children's health insurance program. that's significant for a number of children who receive insurance and health care under chip in san francisco and the state. so that will continue. [please stand by]

. >> equivalent to those included in the proposed legislation to dismantle the affordable care act last year. that is just -- it does suggest that there's still not any conclusion to the debates over that safety net funding, despite the fact that we haven't had a wholesale repeal

of the affordable care act. other efforts that have happened or are underway that we're watching closely, there is in the tax bill that the controller's office was just discussing, the repeal of the individual mandate has the requirement the individuals have insurance or face a tax penalty, that will go into effect in 2019, and that's likely to have an impact on the number of people who are insured in the individual market and also affect the premiums paid for those who do remain in the market. at the same time, the administration has made a decision to reduce cost-sharing subsidies. those are subsidies that go to offset the cost of lower individuals receiving health care insurance through state exchanges, so that is likely

to -- [ inaudible ] -- we're watching what that means for our health care coverage and the availability to provide services here in san francisco. other actions are plans by the administration to allow short-term insurance plans. those are essentially reduced levels of coverage at reduced cost, so it's less insurance that you were formerly required to have under the individual mandate in obamacare. that will also have an impact on the individual insurance market, most likely by moving healthy people out of those more robust insurance plans, reducing enrollment and increasing premiums to those who remain. and there's a movement now to impose -- allow states to impose restrictions on medicaid

beneficiaries, including work requirements that could be implemented on a state by state basis. so just in summary, we do have a lot of actions underway, we did not have the whole large full-scale repeal of the affordable care act that was contemplated several times last year, but there still are efforts underway at the federal level to take actions that affect both us as a city government and a health care provider, but also the private providers in the city that could have a significant impact on our public health. so we're working carefully to watch those and work through our process and through our associations to be active in being involved, try to -- to try to advocate for the city's interest, and we are also active with the state, as the state is looking at a number of possible policy responses that we can do here in california to offset some of the impacts of

federal actions or change our health care policies in the state to improve our self-reliance and self-testing. so -- and lastly, just a reminder that the scale of those conversations is large. we've had about 133,000 san franciscans receive health insurance under the coverage expansion options under the affordable care act, so this has been huge for our health care system in the city and for the public health of san franciscans, and so we will be watching very closely and active in all of these conversations about it. so i will turn it over to trent rohrer for hsa. >> good afternoon, supervisors. trent rohrer, executive director, human services agency. i'm going to start actually even though this is the federal

select committee with just a few state issues, simply because the potential dollars at stake are so significant. the first is the cost shift in the inhome supportive services program or ihss, implemented through state senate bill 90, which was passed last year. it's an extremely complicate, very complex cost sharing formula that sb-90 implemented. i'm not going to go through that, but the upshot is that through sb-90, the state shifted about $592 million of cost from the state to the counties to fund the ihss program. san francisco's share in the current fiscal year is about 20 million. this is a combination of our increased minimum wage and increase costs or increased wages for ihss workers due to

the minimum wage locally, and other factors that we've incurred including caseload management in 2012. the $20 million each year will increase next year for the a couple of reasons. one, the seent includ-- county reduced the state offset, and i'm quickly getted complicated, but it reduced the state offset to the county costs 170 next year, and 350 million, after that. so reduced state support and increased costs locally is going to result in what we anticipate 80 million by about 2022. this was largely driven by governor brown and his administration. there is a lot of discussion

among county supervisors' association, csac, and seiu labor to reopen this next year under a new administration, simply because this represents, at least in my 18 years, the largest cost shift to counties in any program under the human services purview. we continue to work with our lobbyists, we continue to work with your parties at the state to attempt to mitigate the cost increases not only in the next fisking year, but again to try to reopen it in the following fiscal year fiscal year, but again to try to reopen it in the following fiscal year. next, we were shorted about $30 million in the proposed governor's budget that was supposed to be accounted for in january and it wasn't, so we're continuing to work with the legislature and finance on

restoring that, and hopefully resee fiscal relief in the may revised. and then in cal revise, which is our welfare to work program, because our budget to support the county operations is significantly tied to caseload, and because the caseloads have did not declining largely due to the better economy over the past few years, our reductions statewide have been about 17% over those past three years. again, there's another $56 million proposed cut in 18-19, which is about 1.5% cut to us. we're working with the administration and the legislature to revise the current budgeting methodology to make caseload less of a factor, really recognizing that there are -- that the cost drivers for the program doesn't have to do just with the families that we're serving aid. one of the arguments is those

who remain on aid have not availed themselves to work due to the good economy, so using just a reduction due to caseload doesn't make a lot of sense for these families. working with our lobbyists and partners up in sacramento to relieve the cut. and then, at the federal level, the biggest issue is something that will go into effect in september of '18, and this is -- really has an impact more on individuals receiving cal fresh, which used to be called food stamps and less a fiscal issue, but nonetheless, i'm bringing it to your attention. in september, a waiver that the state is currently operating under, which is called the abod waiver -- what is the abod waiver? the abod is an able bodied adult without children, who is aged 18 to 49, and the individuals who are currently

receiving cal fresh who were able to work who are aged 18 to 49 will have to work at least eight hours a week to receive their benefits. that begins in september of 2018, so that's in a few months. in san francisco, it puts about 500 individuals at risk of losing their benefits, and that amounts to about $230 a month. we're developing with our partners, options for work activity to help them not only continue to receive their food benefits but also to help them move into plaemployment and no needing the cal fresh support in the future. and then the last is around medi-cal, which greg wagner already mentioned. one of the things we're concerned about is a movement from an entitlement to a block

grant, which would disproportionately hurt california for a number of factors, mostly because the cost percase in california for medi-cal was lower, and if there was a percapita block grant, we would get a block grant in california that was lower than the true cost of the program. we would no longer to get the 50% or 80% cost percase of federal reimbursement and it would really force the state, you know -- and the feds would call it state flexibility, but in our state, it would force the state to decide what eligibility to -- you know, who to -- how to restrict eligibility to knock certain people off of medi-cal and what benefits would no longer be eligible or offered under the state, so that has not been formally proposed, but the current head of the center for medicaid services is a big

block grant proponent in her past career, so we continue to be mindful of movement in that direction. and with that, i'll conclude with any questions if you have them. >> supervisor fewer: yes, supervisor. >> supervisor tang: tang thank you very mu you -- supervisor tang. >> supervisor tang: yes, on the work requirements fort the cal fresh program, what were those work requirements? >> it's 20 hours a week of any sort of work activities from work fair, which we currently have for our cap recipients to education, job trainings. i should note that we are allowed to exempt at least 15% of individuals from these requirements if we determine they are unable to work. these categories are pretty broad, and they can be locally defined. so we're looking through the 5,000 who might be meeting the

work requirements right now to see how many we can exempt. we also have the option to i don't want to use the word steal, but to use exemptions that could be applied to other counties because the way that the state does the exemptions, it's 15% of the statewide caseload, so if some counties aren't using their full 15%, we could actually use some of their 15%, so we're working with our colleagues in other counties to see how much above that 15% we might be able to go. >> okay. thank you. so 20 hours a week is the requirement. and then, in terms of the iihs cost sharing, i know we talk about this all the time with the mayor's budget office, and of course you reiterated the huge issue we will face in really the near future. i'm wondering if we are thinking about -- this may be a question morfore the mayor's budget office, but how we in the last budget season had a federal reserve, state reserve, if we're thinking about that.

but we anticipate the numbers or we have kind of an estimate of the numbers coming up, so i'm guessing that we'll put it into the budget proposal. >> thank you, supervisor tang. kelly kirkpatrick, active budget director. those numbers are included in the updated deficit that we just published yesterday. however there are other potential risks that you noted, and throughout this whole presentation that might cost the -- the city and so we are thinking about, you know, an ability to reserve against those like we did last year, which was a very responsible move, especially since we utilized that in december to cover a handful of costs. so duliet noed, and we'll definitely take that into consideration. >> thank you. >> thank you. >> supervisor fewer: thank you. any other questions? >> thank you. >> thank you very much,

director. let's open this up for public comment. is there any members of the public that wish to comment on this item? seeing none, public comment is closed. colleagues, is there a motion to continue this item? >> to the call of the chair? >> supervisor fewer: yes. >> okay. so moved. >> supervisor fewer: thank you very much, so we can take that without objection. thank you very much. madam clerk, are there any other items before the budget and finance federal select committee today? >> clerk: no, madam chair. >> supervisor fewer: there being no further business today, we will adjourn the budget and finance committee federal select committee, we will return to the regular calendar. >> clerk: madam chair, can we please recess this meeting until supervisor sheehy -- oh, there he is. >> supervisor fewer: we now from forum, thank you. >> clerk: item number two, hearing to receive the fiscal year 2018-2019 budget and policy priorities from the

department of public health, home -- human services agency, department of ageing and adult of thes and the office of early care and education. >> supervisor fewer: thank you. we are hearing presentations today from several department heads. let's begin with barbara garcia, director of the department of public health. >> good afternoon, supervisors. barbara garcia, director of health. wan wanted to give you just a quick overview of our 2018-19 budget. as you can see, zuckerberg is almost half of our budget, but

i do want to highlight the behavioral health component which is a large component of our base budget, and then the rest of our services, as well. one of the important -- what's really important for the department is to leverage about $1.4 billion in revenue. much much this of this is matc when you heard about trying to reduce medicate dollars on the federal level, we use general fund to offset that. it's really important, in terms of medi-cal does have very strict rules about who can be billed for, so one of the areas -- and you'll see in our budget how we really focus on areas like zuckerberg behavioral health to ensure that people are at the right level of care so that we can maximize our drawdown of federal dollar match. this basically shows you the

revenues that we create, as well as the general fund subsidy as part of that that shows the expenditures of the $2.2 billion. our areas of focus for 18-20 for our budget will be to continue implementation of our major initiatives, maintaining our core health services, a focus on equity, and equity is one of our goals, not only for the city overall but also for your department. some of you have seen our process in bringing force our budget request and also our proposal for our electronic health records. financial stewardship is a really important part for us. as you can see we see a lot of potential areas that we could be impacted from the federal government, so we've been trying to really manage our budget and also manage our expenses so in case of the future. to provide incredible resources

and also services to the community, we are -- have an initiative, of course, to develop our people, which means developing our workforce. and also one of our most important roles, of course, is to provide services for our vulnerable populations. this year, we'll be -- for next fiscal year, we meet our reduction targets through our increased revenues, and we have no service reductions, but just want to let you know that you may find out from other cbo's what we may not know, which is at times whether they are losing federal reductions or state dollars or foundation dollars, but we've really tried to work closely with our community-based organizations to ensure we know what types of funding they may lose and this year, we'll be backfilling 4.1 million of hiv health services, std disease control,

emergency preparedness. as you can see, these are core health functions that we have, and we are finding and seeing state and federal reductions to those. and i think we've been all very proud of being able to backfill those on those cuts. we have been finding that our hospital, zuckerberg and laguna continue to have more patients coming in the doors, and so we are having increased costs of 7.8, but that's also offset by revenues by the medi-cal drawdown as you saw in terms of what we do. we're also very proud of the alfiation agreeme afilliation we have with ucsf at zuckerberg, and those are ongoing costs that we are responsible for to make sure we have our hospital provided

through the position agreement. the focus on equity, over two years ago we started a black african american health initiative. this was really an internal process to look at how well we were serving our black and african americans within our health department, and we've done a lot of work across the department to ensure that we're looking at high blood pressure, to ensure that we're looking at asthma, and that as really work internally in the department to really focus on how to improve overall health care and overall health touches to the black african american community in san francisco. we are also now really reaching out to our cbo's and to other community agencies in the following years, but we felt like we had to really work within zuckerberg, laguna honda to ensure that we all really do have a focus on black african american health. over the last couple years, we have been working with hope sf, and i've been working with hope sf process for over five years

in really developing wellness centers in all of the rebuilds of hope sf, and all of these wellness centers are really to provide a way for navigation to -- back into care. what we find is many of our community members in our housing authority do have access to insurance, do have access to medi-cal, but at times, they are not attending to their physicians, and so this is an opportunity for wellness, and it's really focused on mental health, as well as focused on nursing services to ensure that people can come in, get their blood pressure taken care of, and also have some conversations about how to get back into their primary care centers. we're joining forces -- as you may know, one of our incredible health directors went to become the alameda health director. today we have our regional area filled with people that kind of graduated from the health department. so marin county, san mateo county, alameda county, and we're working with our bay area

regional health and equities initiative to really bring the directors of health at least from the contiguous counties to think about regional approaches to the work that they've been doing. the county -- we've got a bond of 2016, and we are going to be rhenvating and expanding our southeast health center. this is a -- a view of what it will look like, and that's a $30 million renovation. the fact that we are an aca provider, electronic health records systems, we are bringing in to replace a major legacy clinical and billing systems, and this is our billing systems that you can see as i discussed with you for medi-cal is responsible for over $650 million of annual revenues. the electronic health record system will not only be an ability to bill better but also

to ensure that our providers have a full view of the clients and patients that are coming to our system. we have over 60 to 100 applications that -- and we're really trying to integrate many of those into a new electronic health records system, and that's a very expensive endeavor that we are trying -- we will be funding for the next ten years. our first phase, go live date is august 3rd, 2019, and it does require comprehensive staff engagement, outreach for -- over the next 18 months. we have 7,000 employees to train in the system, and again, it will cost us 383 million over the next ten years. financial stewardship is an area that both our cfo and myself and all the leaders of the department are very focused on. as i discussed, we leveraged 67% of the budget from revenues.

our largest revenue source is our medi-cal and medicare. we have met general fund reduction targets through revenue and supports of our five year financial projection. that does assume revenue growth. revenue formulas are changing from fee to service to value-based payments from the federal government, so no longer are we counting the number of visits, we are now counting how well people are doing. and so we really have to earn our dollars by ensuring good outcomes, good health care for our clients, not how many we serve, but how well we are serving them. and as you heard from our federal oversight today, federal policy changes do create an uncertainty for us, and if you think about medi-cal being 30% and any reduction in that area, we'll have a significant impact on our future of health care in san francisco. developing our people means developing our employees.

we have implemented trauma informed systems of care to promote organizational change through understanding the effects of stress and trauma on individuals and families and communities. and we are very proud of a regional approach that we've been doing this with. some of our staff are involved in training not only our staff but staff from many of the contiguous counties, and i think we've trained altogether 10,000 individuals throughout this area. we embarked on the last kefsevl years on trainings and engagements in cultural humility, and supports diversity. i do want to say that we have one of the most diverse workforce in the city, and part of that is really insuring that

the people of color in our system and our employees really do get respected and also the fact that other people in our department also get training to ensure that we're serving the communities that reflect that. for the last several years, almost five years, we've been involved in lead management training for continuous improvement. this is a process in which we look at waste in the department and try to ensure that we engage our front line workers and also develop standard work. we found that in -- as an example in our emergency room, we've been able to fast track an emergency room line as a way to really get people through our system faster, and that was done through or lead management process. just to outline some high level behavioral health services for some of our most vulnerable populations, we have over $300 million in mental health services that include long-term

care, residential treatment, outpatient clinics. we developed a street medicine team, and as you know, in our -- you've heard today about the opioid crisis. we are not waiting for people to come to us, we are going to individuals who are in need of opioid services. and every day, we provide crisis intervention services throughout the community for any violent issues, including homicides, and mental health crisises throughout the city. we have $65 million in substance abuse services. most recently, we are engaged with a $9.2 million increase and throughout medi-cal, this is the first time that those with addictions have the opportunity to have medi-cal, and so we do have a pilot that's going on. it is a high bar of documentation and certification through the federal government, so we're taking a real good look at what providers we have

that have the infrastructure to be able to meet the standards required by the federal government to be able to drawdown more money, more dollars from our general fund. we received, along with the homeless services and supportive housing department, about $36.1 million waiver. what this is, that we have to earn the $36 million through a work together on whether we're doing -- we have a behavioral health engagement team, a psychiatric emergency services bridge. we also are looking at data sharing and platforms for stakeholders. this will mean that both the homeless department and the department can share data with each other, share data amongst our most vulnerable populations to ensure that we are working together in ensuring that we work with the most vulnerable populations who are homeless on our streets. over the last several years,

we've developed a shelter health program in which we will engage with bringing nurses similar to the wellness centers in hope sf. we actually modelled it after this program, shelter health, which provides nursing services within the shelter system, and we found this to be incredibly important. prior to this program, the top emf caller in our service system for ems and ambulance service was next door shelter. and today, that is no longer the case because the nurses are able to triage people at the door. we are able to send them to medical respite and able to engage with the hospital if necessary, so i think we've done a really good job of reducing ems calls and ensure that people are getting the right level of care. and we expanded medical respite just for that, to ensure that people in shelter who are not thriving well due to their health conditions can be moved

to the medical respite. and you will see and you hear a lot about syringe access and d disposal, and i have to say with the last numbers that i received from dpw, those are reducing, not because we've reduced the number of needles, but because the department has really worked at trying to engage all of our youch reaout workers. we have a rapid response team, we have a kiosks in order to reduce the number of syringe disposals in the city. then, we're really proud of the jailhouse services we have in the city and we've done a lot of work there, including bringing a stronger psychiatric service to jailhouse services and really connecting the discharge from jail. as you know, many of the individuals going to jail do not stay there long, and it's really important to do that transition for them. okay. i think that's the end of the report, and i'll take any questions. >> supervisor fewer: colleagues, any questions for

miss garcia? supervisor sheehy? >> supervisor sheehy: so where are we on behavioral health capacity for mental health capacity in the system? i know you added 54 beds at st. mary's last year, and about what, 15 at hummingbird? >> we have over 300 beds in the community, and that's one of the things we focused on this last year, where we brought in over 100 beds. we're just doing a review of the number of beds potentially that we could expand to, but that is still in the process of development, and it doesn't take -- one of the -- one of the issues for the federal government that may change and that the new opioid bill, presently today, we can not bill for anything over 15 beds. they changed that a bit for the

substance abuse side, and that's because the government are the experience of institutionalization of mentally ill, and so we are no longer allowed -- we cannot bill anything over 15, 16 beds. so as an example in the st. mary's facility, that is all general fund. so that law may change as the institute of mental disease, that may change on their -- on this new piece of legislation. it's something that we think is really important on the mental health side. on the substance abuse side, on the state level, because we had groups like hr-360 that already had 200 beds, they really fought for the exemption of that. and so we do see that there's the potential of lifting that. that would really help us because this -- as an example, our latest facility, the 54 bed was all general fund. we could not bill any medi-cal for. >> supervisor sheehy: and then, i'm trying to understand, what is the -- kind of the

interface, like, for instance, someone goes to hummingbird or to -- or to st. mary's or they're at 360, and they're in a substance use. if they were homeless when you brought them in, what happens to them when you get -- get them stablized? >> right. as one of our doctors says, homeless housing, right? we really have to work at the first day that they come into our programs to really start getting -- making sure they're where they are in their benefits, are they on ssi. it's a really long wait sometimes, and sometimes that wait is longer than when the housing is available. so sometimes we do try to work with organizations that have step down places, different levels of care that they can move individuals down. that helps with lengthening their length of stay at the facility to see if we can get them a housing bed. but it is something of an area

that i know i've had conversations with you supervisors regarding the amount of spending on our individuals that go to our program, and then, we have no other alternative with them but to let them out the door back into the streets. i've been working very closely with the homeless department to making sure we do the coordination, as the date gets closer that they get their data system put together, that we work with -- that's when people are most stable, when they've just done three months, six months with our department, and they've stablized their addiction or stablized the mental health issues. we know this is a long-term chronic disease, and that's the opportunity for us to really work with the homeless department to ensure that the clients get prioritized. >> right now, they're not prioritized. >> right now, it's a very difficult process to determine how the formula is what the homeless department is working on, but we do get some individuals in housing through our programs, but i think we

could do better in terms of the way we coordinate that, and that's part of that whole person care model, as well. >> supervisor sheehy: when someone -- to what agree is the acuteness of someone's health need factored in by the department of homelessness. >> that's being worked on with them. we're working very closely with them. the whole person care program that i discussed, that's one of the major focuses. we're going to have a vulnerability in that that gives an objective view of how acute somebody is, and that will be measured out with the number of years that they're homeless, and that will be a factor in that, and i think that'll be the model that we're trying to go towards. and that has not been totally incorporated yet, and that's an area that we're still working on with the homeless department. >> supervisor sheehy: yeah, because i'm hearing anecdotally from people in the health department, it used to be much easier for people with hiv in

getting a place to stay, but that's becoming more of a challenge. we give people with hiv medications because they're sick, but they're back out on the streets. eventually they end up in the ed at san francisco general with full blown aids, and so -- >> yes, sir. well, that i think is a whole city emphasis in trying to get more affordable -- ability of housing, getting housing developed to people with acute illnesses and with homelessness, and it's something that we're worky -- working really hard on with other departments. >> supervisor sheehy: no, i appreciate that. thank you. >> supervisor fewer: yes. supervisor stefani. >> thank you so much for your presentation and thank you so much for your push to provide that san francisco healing center and to provide those 54 more beds. i'm just wondering how many more beds do we think we need to address what we're seeing on the streets, and specifically if senator wiener's bill

passes, and what are we looking at? i get asked all the time, what will it actually take to address the problem and really help those who are suffering on our streets? how many more beds is it? do we have an understanding or any type of idea on what that will look like? >> i can tell you we provide percapita than any other county for beds. i think you have the combination of the lack of housing -- that's why this last year we put another 100 beds on-line in anticipation they were going to get more housing. and so the level of care that we developed at st. mary's is the next level of care next to a psychiatric and inpatient stay. and we don't want people at that level of care. we really want people atloer levels of care and into

housing. the fact that we have a methamphetamine epidemic right now does make it very hard to kind of estimate what our numbers are, but we do know that i'm still working on expansions of some of our other programs, and we are trying to find that formula. i believe that we have more beds than any other county in -- in this state, and if we can get the free -- of the freedom of the ability to build 50%, we can develop more beds. but to have 50 more beds, costing us $50 million, a respite of between 5 and $10 million, that's pretty extensive. so to give you a number of 100 or 200, i don't think that would be fair, but in future hearings, we'll try to come closer to what the future maybe require, but our