>> lilo joined the wag brigade as our firs first pig. >> wag brigade invited us to join the program here and we have done it about a year-and-a-half ago. our visits last 1.5 to 2 hours and it does take a little bit longer to get out of the terminal because we still get a lot of attention and a lot of people that want to interact with lilo. >> i feel honored to be part of the wag brigade. it's very special to meet so many people and make so many feel happy and people that work here. it's been a great experience for me and a great experience for to

totoby. >> it's been an extremely successful program, so the next time you are here, stop by and say hi. >> good afternoon. the commission will please come to order and the secretary will call the roll. >> clerk: [roll call] the second item on the agenda is the approval of the minutes of the health commission meeting of january 8, 2019. >> the minutes are briefed for the commission a motion for acceptance in order. >> so moved. >> second. >> any corrections? if not, all those in favor please say aye. all opposed?

and the minutes have been adopted. next, please. >> >> clerk: item three is the director's report. >> good afternoon, greg wagner acting director. on january 7 last week ou new governor gavin newson enacted the first budget of the new administration. and the budget has a number of items aimed at increasing access to health care and other health care related issues. included in the budget is a plan to reinstate the individual mandate formerly the federal mandate at the state level and expand health care for undocumented immigrant up to age 26 and increase the drug purchases and give the state

greater leverage in negotiating prescription drug costs and requesting for a single-pair government-funded health care system that is obviously going to be something that take some time but it's a first step in em mroerg some significant changes and establishing california surgeon general position charged with health equality in the state. the budget process will continue and we're actively working through our channels to make sure we understand the proposals in the budget and have a voice in that conversation. but i think a lot of the proposals are moving in a direction that is consistent with where the city's legislative agenda has been pushing so we'll be actively involved in that going forward. on january 9, i'm sad to report

it was announced the first san francisco resident who as died from influenza this season. we want to acknowledge the impact of influenza and as a way of reminding people the importance of getting flu shots and taking preventative measures to try to limit the impact of influenza in the city. on december 20 of 2018 the san francisco food security task force released the foot security in san francisco and you're familiar with the report and we'll be discussing it shortly. the report examines data from federal, state and locally funded food programs and develops recommendations to close gaps in san francisco. more to come on that shortly. we recently marked the one-year anniversary of our law

enforcement assisted diversion program also known as lead. that say program that we have implemented as part of a state grant funds a year ago and has been in activity and the goal of the program is to reduce recidivism and increase their housing status through agencies an community-based organizations. this has been one of our active and partnership opportunities with a lot of the other city agencies we work with, particularly in the law enforcement world. it's been a very active program and we're carefully watching and monitoring learned lessons and develop data to develop the effectiveness of the program to continue to move forward on that very important one for us. we received a $75,000 grant from

the california office of traffic safety. that grant will fund a yearlong program focussed on community outreach to pedestrian and to homeless and marginally housed residents and that will be a community engagement and education activities we'll be engaged in. as the an additional component to leverage everything we're doing through our vision zero partnership i know the commission heard plenty about is is an ongoing effort to get to zero pedestrian fatalities an injuries. lastly, josé alberta from our staff has been selected from the county behavioral health association to receive the 2018 story teller award as part of the cbhda second annual awards

recognizing the impact of individuals in the field of behavioral health so congratulations to josé in appreciation for the recognition for the work that he and his colleagues are doing in behavioral health. >> thank you. commissioners, any questions to mr. wagner? in regard to any of the subjects? first, how did the governor propose to bring back the individual mandate which i thought was a federal mandate? >> so, it was a federal mandate. it was eliminated during the deliberations at the federal level last year. the proposal would be to reinstate that in california. there would be a program that mirrors the federal individual

mandate essentially a requirement that individuals would have insurance coverage and if they don't comply with that, there would be a penalty that's a tax penalty and that's the same structure that was included in the federal program so of course for individuals that have difficulty affording coverage on their own, the program much the affordable care act did, the state proposal would add other opportunities to improve affordability of health care for individuals and that would be in the medicate expansion and it would also be in programs to revise the subsidy program for purchasing programs under covered california. there will be a number of things we still need to learn about terms of details and it will be an issue discussed and worked through over the next many months as we come to the

governor's may budget revision and we'll be actively working through that and watching that as the discussion goes and report back to the commission. >> thank you. commissioner chow. >> i wanted clarification because what i learned is it the governor's office has to ask for permission from the federal government in order to do this. but i'm not clear they're going to have the same policy in terms of individual mandate. do you think it will be the same? >> i don't think it will be identical. on the question of whether we need cms approval for the mandate. >> i don't have a clear answer on that. that might very well be the case but i can follow-up with you.

i don't think it will be the identical program but would be the same concept you would have that was when the affordable care act was put into place it was one of the supports that held the program up is you have a requirement for insurance around subsidies to access that and by doing that you increase the pool of people in insurance and thereby allow other burdens such as the pre-existing conditions the requirement p pre-existing conditions be covered and it's modelling what was in the affordable care act and recreating it in california but it would be probably modified and tailored to the situation as a state.

>> so -- >> commissioner: so the question i have i believe originally that we don't call it a penalty, i forget what we call it, a fee for those who did not have insurance for the year to actually be paid through the federal tax irs. this makes me wonder. as it not much of a mandate if there's no real consequence to it. >> as we learn what the proposal it we'll discuss it with you. my assumption is it will be similarly administered via the state tax system. that would be using state tax code versus the federal taxes.

>> commissioner: any further questions, commissioners on the report to ask mr. wagner? no. okay, thank you, mr. wagner and go to the next item. >> there was no public comment request for the item. item four is public comment and i've not received any request. >> we'll move forward to the next item please. >> item five is a report back from today's community and public health community. commissioner weis. >> thank you. we had a very inform stim and challenging mete meeting with regards to presentations. today we had three presentations one was the balance prevention and crisis intervention update which i'm sure my colleagues would agree was informative and helpful to understand where we were 32 years ago in terms of the department's response to critical incidents and where we

are today and the linkages that occur for those folks who are victims of and/or perpetrators of violence and community and how we linked those folks who need services to the array of public health as well as a balance of services and how the staff is embedded in community to address the issues as they emerge in the southeast sector and the mission and other parts of san francisco as shootings occur they're activated as a team. as a team they assess the issue and work with police and the health department and other necessary agencies an within 48 hours someone sought in community and win an hour

they're doing work but doing a more detailed plan within 48 hours. they meet as a group with police and other first responders to address further plan for community as well as for the victims and the families of those involved. so if have you additions you want to make to that particular presentation, feel free to do so. seeing none the second part was the behavioral health presentation. and it was insightful and helpful. one thing i found interesting in the report and that had to do with the reduction by approximately 39% and the wait time to be removed from the jail system and to take psychiatric

treatment and they went from 2015 to 220 days incorporated approximately 70 days people were incorporate -- incarcerated while waiting to get into psychiatric services and they can do conservatorship why ch -- which is an easier accent point than from where the standards are different at the hospital and challenges that emerge are extreme. so this is something that's going to be helpful and useful to our population and those were two things. there were many things discussed in the report so i'll defer to my colleagues asking if there's additional things you were interested in reporting out to the commission. seeing none i'll move on to the last piece. the last piece was a resolution presented by former commissioner

to address public health concern. the committee decided there were edits that needed to be made to the resolution. so as a committee we are moving to the department so the department has the opportunity to address the necessary police reports particularly in the resolves. more specific data and rather than saying we have the reports are and say what the department's role will be in the regional health services across the broad notion of what goes on in a jail and not the health department has many roles to play and the commission was

concerned there's not a high level of specificity and we agreed as a committee we would bring it back for the very next community health meeting on the third tuesday, february and at that time hopefully we can take a vote and go to the full commission for discussion. colleagues, if there's comments you want to make in addition feel free to do so. >> i want to go back for the remainder of the commission that wasn't there on two points. i thought they wanted to add to one is in the components they were using is an ability to help connect those who are in need to employment.

that is unique in the type of program we have here. the bay area homicides have in fact plummeted on the last page of the presentation. commission should be aware the homicide rate looks it is -- it's going to be the lowest in over 50 years. i did ask a question in general that how did that actually compare with san josé and it was very interesting that the components that we have to deal with and the problems we have to deal with here are much more complex because we're a more compact city and also beginning with the fact san josé apparently has flee three major -- three major gang type of violence but here in san francisco we have more

complexity to that and we also are dealing a lot more with people who have their roots here but are more cosmopolitan area. i felt the commission should be aware of that actually in spite of the rate. our rate is significantly different if you look at the data and you may we will have also seen the likes of a week of the year where the chronicle actually highlighted this quite lively. but without you realizing and that's what's good about this there is this street violence intervention program and they did also note san josé has a very similar program and they feel these are effective and we're looking -- i think at outcomes now at some of the programs and we should be really proud this has been happening.

i have a small request because of the way the program is focussed, they were focussed on where most the violence is but ask they also might help us take a look at the chinatown experience and see because there apparently is another element of workers who work with those areas and just to get a complete picture whatever we are doing in terms of violence. though this group does handle wherever the violence is even though they are committed to certain high-risk populations. so it was an excellent report and it would be worthwhile for those who have not reviewed the presentations to really take a look at it for that reason. we'll ask for outcomes a lot and here is a report of a program that really also then has

outcomes as a result of the work. >> thank you, commissioner chow. >> there was a real time administration of the work done a lot of the shootings on la sal this weekend where one person or two people were deceased and they talked about how they activated to address that and the team did their work and westbound able to demonstrate and identify how they did the work and the impact it has on community. i was happy to hear in real time and we had to hear as a results of a homicide but at least we understand in a reel way what they do and how they do it and how they're connected to community. >> any questions or comments in regard to the committee report? i want to commissioner loyce on

the lively committee meeting. thank you, on to the next item then. >> clerk: if there's no public comment, item six is a resolution authorizing the department of public health to recommend to the board of supervisors to accept and extend retroactively a gift to the la gue ga honda gift fund to the friends of the laguna honda. >> thank you, directors of the health commission and director wagner, happy new year. to ask your approval of the resolution that's attached friends of laguna honda are a non-profit that support the volunteer programs and our resident programs donated 14$1,000 and technology and elder and music programs and all

to benefit our health and well being of our residents to promote their quality of life at laguna honda and i'm here seeking your approval of the resolution so we can submit to the board of supervisors to accept and extent the money gifted to the resident gift fund. thank you. >> are there questions? if there are no questions then the resolution is before you for a motion. >> moved. >> second. is there further discussion on the resolution? we're very thankful to the friends for doing this year after year i understand this is a new format they're making this in the last year or two.

>> they're more focussed in terms of where their donations are and for the calendar year. they wanted their donation to benefit still the quality and well being of residents and to benefit the music program and to provide outward elders and technology and centers for excellence. >> commissioner: those are areas the staff agrees with and encourages? >> yeah. >> commissioner: thank you. further questions at this point? >> clerk: commissioners before you vote, there were no public comment request for the item. >> commissioner: any questions in regard to the resolution. ? if not we're prepared for the

vote. the resolution has been passed. thank you. >> clerk: item seven is a resolution with food security and endorsing the food security task force 2018 assessment of food security in san francisco. dr. johns. >> good afternoon, president chow and acting director wagner. i am here to give you an update of what happened since the last time i was hear and talked about the resolution and assessment we finalized and it was filed in the san francisco chronicle and there's articles being writtin for local newspaper. this say topic many in the community are interested in and we're following up with the board much supervisors around the data for the district. we've received a lot of interest in light of public charge and

the government shutdown and how it may be impacting cal fresh recipients an brought six new members to the task force to bring expertise to areas highlighted by the report. the board of supervisors is interested in schedule hearing to present the report and recommendations the task force is revus the data to provide additional recommendations for funding and programs. one specific update that was requested around the recommendation on page 183. that was around supporting the health care systems to integrate into new and existing electronic health records the term for food security screening. i know this has been happening and reached out to the chief of community primary care who is

really in charge of this for the epic rollout and said questions are available in the epic rollout and the two item screen will be available in the rollout and then primary care is actively screening patients for food security soo -- so when epic goes live they'll screen and applying the directory to be used for epic to refer those with food insecurity to resources in the community. before you is some amendments to the resolution you requested last time.

>> there are several public comment requests. >> we'll proceed. dean deanna lam and veronica shepherd. >> i'm geena lawn from the san francisco clinic consortium and i'm here with a collaborate that seeks to promote health in san francisco. the sf hip is responsible for helping to develop the community health needs assessment. we wanted to support this food insecurity report and note that this year food insecurity rose to one of the primary concerns expressed in seeking input in the community health needs assessment. thank you. >> commissioner: thank you. next, please. >> good afternoon, commissioners and acting director wagner.

i'm the chair of the food security task force and work on meals and wheels. thank you for reviewing our report and resolution and providing comments. we hope to see approval of the resolution today and take it as a model to the other commissions. i want to commend you for hopefully being the first to pass this resolution so thank you. >> commissioner: thank you. next, please. >> good afternoon , commissioners. i represent many hats and i want to thank you for the wonderful food security resolution. for the people i represent in the bay view and our low-income populations, they're very hungry. this will help begin to lift up. food is critical to everything

we do in life. having you look at this, review it and understand the importance it impacts our community is critical and will make my job easier when people are calling me looking for food. thank you. >> thank you very much. commissioners, the resolution was introduced several weeks ago and we request a certain modifications and they're incorporated in the resolution before you. do we have any questions or is there a motion to move the resolution? >> commissioner: proceed with your question? >> i know the federal shutdown has some responsibility for food security in terms of quality

food and passing of disease to community. what impact have you seen locally in terms of the shutdown, if any? >> there's a lot of concern. there's a lot of fear. we're getting questions from specific supervisors about their district because share very worried about snap, cal fresh. there's been a lot of in the media about potentially not having the budget and the usda said we have the budget until february but it has to be allocated by january 20. so there's a big communication going out. food stamp cards will be loaded with their february benefits tomorrow. they're cautioning to everybody you went get more in february necessarily because it's the february allocation. beyond that it's not known. we're hearing day by day. that's one of the biggest concerns we're hearing around

cal fresh. >> commissioner: thank you very much. >> commissioner: thank you. so commissioners, a motion for acceptance. >> so moved. >> commissioner: second. >> commissioner: and there's a second. okay. further comments? we want to know when we first saw the resolution it was with a draft of the food report itself. and commissioners, as you know as you've reviewed it it's one of the most comprehensive reports i think we've seen. the demographics for each of the districts are certainly well worth just keeping along with all the data that comes with it and the recommend. i want to commend the task force for having done such a thorough report. >> thank you very much.

comments or further changes to the resolution. if not prepare for the vote. all those in favor of the resolution please say aye. all those opposed? the resolution has basketbaeen and the commission commend you again for the work you've done. >> thank you very much. >> commissioner: please. >> i want to make a short comment. my mother has been serving with the food bank for a while now and she would be excited to hear about this resolution and what we're doing here in san francisco. >> it's really important. thank you. >> commissioner: thank you. we'll move on to our next item, please. >> clerk: item 8 is a resolution approving the san francisco department of public health 2019 state and federal legislative plans. this is a discussion item today. you all will vote at your next meeting on february 5.

>> okay, thank you. >> good afternoon, commissioners. i'm director of the office of policy and planning. i'm hear with a team member, max gara sharing the presentation with me. i'm recovering from a little bit of a cold so apologize in advance for any sniffling or sneezing and have you a summary of the 2018 action and copy of our draft state and legislative plan and a copy of the resolution before you that approves the platform which will be voted on february 5. i will not be going into detail to the policies but i'm happy to

provide additional information to the commission between now and the next hearing. so today i'll be providing background on the legislative background's purpose and the development process. i'll be provide summary of some of the actions we've taken at the state and federal level over the past year and review emerging issues in 2019 and max will talk about the development of our state and federal legislative plans. so we prepare two platforms every year and they're aligned with the priority and mission and serve for guides for monitoring proposals and identifying policy issues the city may choose to take action on. the plans are informed by using input by department leadership and subject matter experts in the department and policy

organizations. and they're intended to cover a broad range of health policy issues that may be addressed by lawmakers in the coming year. the plans help assist dph staff. when it comes to the presenting the department's view on any particular issue. the health commission generally approves the plans before they go to the mayor's office for approval where they're incorporated into a larger city wide plan. however, this year the plans have already gone before the mayor's state legislative committee but they're willing to incorporate any feedback the commission has and we can submit that through an amendment process next month. so how do we advance policy positions through the department. this depict what's that process may look.

-- . it provides it into the plan and looking at the first step dph staff work with leadership win the revision to review the bill. the bill will come to the office of policy and planning who will consult with other professional organizations, department leadership, etcetera. after what we determined what that will be we take that to the legislative committee which meets on a monthly basis so any recommendation has to be approved by the mayor's office. after that happens, we will work with staff to write a comment letter to engage with staff and for certain high-priority issues

it may be providing expert testimony at the state level and the city's contracted state and federal lobbyist advance that position through the state or federal legislature. in 2018 we actively monitored over 100 bills that may impact the department. we took a position on 11 bills outlined on page three of your memo. four of the bills were signed into law. some key issues, one is around overdose prevention sites and we supported a bill that would authorize san francisco to launch a program and that was vetoed by governor brown and we expect a similar bill this session. another issue was around conservativeship and it was a

bill that provides a conservatorship for those with mental health and frequent users of services. it passed and it's at the board of supervisors level to make a determination whether to implement the big locally. other areas around ems alternative distinction and this took the form of several bills this past session. none mede it through and the bill veto governor brown ensure the pilot can continue. . other key issues include s to 340b drug pricing which could deplete savings for the department for hospitals an clinics.

we increased access to bill for medical patients and expansion for long-term care services. we provided comments regarding food safety that allows the jurisdictions to develop microenterprise home kitchen and support legislation around the child and adolescent health to accommodate lactation requirements and one of our serviceful bills was vision zero with we were able to advocate public health be include the at the table for a new state-wide task force looking at traffic fatalities. in 2019 we're expecting this to be a fairly busy year in terms of health policy as director wagner outlined some of the proposals that came through governor newsom's plan and this

is increasing ages between 19 to 25. another is increasing subsidies for covered california for those who are win the range and adding new for addressing affordability concerns. those subsidies would be funded through his next proposal which was the individual mandate. the governor's office expects they'll generate $500 million and that would then be used to support those subsidies. and commissioner chung getting to the state with a tax it will

have to be approved by the legislature. i think it will require 50% of the vote. and then the other areas are around controlling prescription drug costs and then establishing a california surgeon general tasked to looking at equality in the state and following the plan governor brown released a budget proposal which is a 4% increase over the previous year. there were several investments in health including the ones we just talked about as well as $100 million and support workforce investment and value-based payment and said he's going to fundamental health to see the issue in the state and coordinate services.

i think by the next health commission meeting we'll have a budget update and will include additional information on those proposals. the upcoming cycle marks the new session with super majorities in both chambers. key issues are around health care. we've seen behavioral health parity and of medical and childhood education and homelessness. just an update on the key federal issues. with regard to the aca the individual mandate happened at the end of 2017. that went into effect january 1,

2019. we've also seen new legal challenges attempting to repeal the aca. in december a federal district court in texas said the aca was [indiscernible] and the aca remains intact as we expect the issue to make it through the court system and ultimately the supreme court. with regard to immigration, public charge was a big issue for us this year. in october the administration issued a proposal rule to the way public charge is administered. when someone is about to make a determination whether they're going to apply for their green card, immigration officials can look and see what services they have used in the past and make a determination whether it will count against their application

to get a green card. what this proposal does is expand the services are to include medical. we believe if the proposal were to go into effect we may see decreases in enrollment in medical due to fear. the mayor's office coordinated with the department of. public health and other agencies to do an impact analysis and look at what the impacts may be and submitted for more comments on behalf of the city. we saw issues ash women's health. we know the administration is pursuing abortion restrictions on title x. so the proposal would prohibit health care providers from being able to perform abortions who receive title x. this is something we'll continue

to monitor. similar with lgbtq right. there was a proposal leaked that indicated they would be a narrower definition of gender and that's something we'll continue to monitor this year. finally with behavioral health issues around data sharing continue to be a priority for the department. federal law prohibits sharing of substance use information with providers and that's something we'll continue to work on. we saw positive development through the opioid legislative coverage and allowing coverage of residential treatment and student-athlete for mental disease facilities that are larger than 16 beds.

i think with that i'll stop and turn it over to max to talk about the platform. >> good afternoon. i'm max gara and i'll be provide overview of the department's o proposed state and federal legislative package for 2019. we worked with leadership and content experts across the department to review the platform and identify emerging policy issues. areas covering the platform are not too different from last year and modifications have been minor. we made updates for policy and renewed funding for chip and provided stronger supportive language on issues where the federal government has taken aggressive action on like lgbtq rights. for the 2019 state platform, we

based on intersection with the department's two divisions the san francisco health network and population health division. while issue areas are based on who we most likely reach out to to understand the impacts of a policy, those will work with subject matter experts across the department to evaluate and weigh in on policies. frem, while the population health division is involved in prevention smoke efforts it has a direct impact by lowering the instances of chronic disease and lowering the overall burden on the health system. rather than reviewing the entire platform i'll highlight several state legislative issues the department expects to encounter in the coming year. medical and health care reform condition to be important issues. we'll continue to support state legislation that combats federal

actions to rollback the significant coverage gains made in california under the aca and will monitor proposals including those that expand service for undocuments rez dents -- residents. there's already been a proposal to expand coverage for this group of folks. substance abuse issues continue to be a major priority and to we'll monitor bills that address parity gaps as there continues to be significant disparities in the level of reimbursement and coverage between physical health and behavioral health services. we'll also monitor proposals for health programming and we expect a version of ab186 the overdose prevention bill to be re-introduced this upcoming

legislative station and we'll be following when it is. we'll support opportunities to support health equity through dedicated funding for public health prevention. in the past several years there's been increased movement to create a california wellness stuff that establishes a sustained funding source for initiatives for health equity and monitor proposals that aim to achieve this end. next, i'd like to discuss the department's proposed 2019 legislative platform. in given the broader categorization we didn't organize them by departmental division. i'll review several issues the department expect to encounter in the upcoming year. we'll continue to support efforts to maintain key aca provisions for access to insurance including the medicaid expansion and market reformed and the state health insurance

exchange. while repeal and replace legislation is less likely due to the changed composition of the house of representatives the federal administration can still take other measures to undermine the aca and closely monitor for the actions an continue to monitor proposals that impact institutes for mental diseases or what is referred to as the imd exclusion. under federal law medicare cannot provide treatment for those individuals with facilities with over 16 beds. cms has announced plans for the state to apply for a waiver to cover um -- up to 30 days of treatment at the imd locations.

we'll continue to watch and away weigh in and we monitor proposals that impact data sharing. sharing data information across patient services can be an obstacle to providing whole-person care. the opioid crisis was expected to modify 42cfr part 2 but this change was not include the in the final bill and it's a federal law that restricts clinicians from sharing information about diagnosis without consent and we expect the health issues to rise in the coming year and we'll be following. we'll also advocate any proposals maintain an balance with reason levels of patient privacy and protection. this concludes my review of the year's plan and we welcome your input on the platforms.

>> that concludes our presentation so we're happy answer question or take any input you have into the state and federal plans. >> commissioner guillermo. >> commissioner: thank you both for your presentation. i had a question around the public charge issue. if you can provide a status report on the status. also you'd mentioned we submitted an impact report and if you can share the data in there that provides implications for san francisco. >> yeah, in terms of the status, so the proposed role came out in october and the deadline i believe is december 10. we're waiting the administration will take time to review the comments as part of the requirement and they'd have to

every comment before going forward with issuing the role as far as the time line we might expect to see it dropped in february or march. and there'll be a waiting period once released from that point to the time it goes into effect will be a 30 to 60-day waiting period before it can be implemented. would -- we did estimates and we didn't use rigorous methods just looking at what the economic impact might be. our colleagues at hsa have seen a decline in the percentage of cal fresh recipients since president trump has taken office. soo we used that as a baseline

to make the estimates so we estimated this enrollment between 15% and 35% and i'm happy to share that report with you and the rest of the commission too if that would be helpful. >> >> one another comment on the impact on the immigrant population and wondering in the office of immigrant affairs and with your office in terms of educating the communities about the impact and any information that might need to be shared in preparation in time for when the ruling may or may not effect them. >> we created communication

materials shortly after president trump came into office. we took at lows and revamped them to change the messaging a little bit and not sure exactly where they are but believe they've been redistributed and nothing has changed right now. all the benefits are still intact and we encourage you to come and seek care and services with us. >> commissioner: commissioner chung. >> thank you for the thorough presentation. i have a question because i think violence don't necessarily always get in the health department's legislative platform but and it got expired for the government shut down and

>> and this for the next meeting. >> commissioner green. >> this is a fabulous report and i'm so appreciative. i'm confused of one or two things. what is the timetable going to be as we see what we're able to do at the state level to block some of these federal changes in particular, how are we planning in terms of healthy san francisco. we have that as an option for people who fall in the cracks and it becomes an issue how you get the word out to people and for people who will fall off the qualification for medicaid or exchange programs.

how we're going to still be able to provide services and make them aware in san francisco they can get help. >> absolutely. in terms of state level action i don't have an answer but any federal action we can look to the state of california to have a counter action there and we've seen that with cases with the affordable care act and rules around short-term haevenlg health plans and imagine we would see certain proposals at the state level to counter act anything at the federal level. in terms of healthy san francisco, i know we have started to have the conversations internally with director wagner and are currently trying to get a better understanding of who would exactly be impacted.

it's through healthy for instance or some other needs. >> commissioner: i'll add, commissioner green, that's where we are in the process of discussing it. we will be here. we're not going anywhere regardless of what the federal government does. that said, i think our first priority is going to be on the advocacy side to prevent these changes. the other thing that we and the city does is work with our city attorney's office as the changes come up and look at whether there are legal actions that can be taken to prevent some of the city government has been active

and it's a policy for a long time the priority is to get people on to medicaid and other forms of insurance and we will push to do that first but we will be there to ensure there are not gaps for somebody who is left without the services they need. >> and they are having the listening session on the national hiv and environment hepatitis strategies. i think that's one change to the plan that they've done for the last two years. we need that. is that and our